Information
-
All non-work-related injuries that cause you to miss work, affects your ability to conduct your work, and/or might be made worse from work activities, must be reported to your Foreman and SoCal Safety Department immediately. Additionally, any non-work-related illnesses that cause you to miss work or go home from work early, must be reported to your Foreman and the SoCal Safety Department as well. Sick or injured employees must sign this form before leaving work, and must also sign this form after returning from an absence. Illnesses that result in missing work for more than two days, and any injury that affects your job requires a signed doctor’s note and job description. Employees with serious pre-existing conditions that could be made worse while working will also be required to provide a doctor’s note.
Form
Non-Work-Related Illness or Injury
-
Please ensure all answers to the following questions have been thoroughly considered and accurate information has been documented.
-
Job Site
-
Worker Name
-
Trade:
-
Illness or Injury
-
Injury Description
-
Work Related Status
Worker/ Authorized Company Representative Statement(s)
-
Allow the worker to clearly state and type their account of the incident.
-
Worker Comments
-
Worker Signature
-
Authorized Company Representative Signature
-
Authorized Company Representative Signature
Incident Follow Up Questions
-
Will this worker need medical clearance to return to work? (PM to decide.)
-
If this person received medical attention are there any restrictions to follow per a LHCP's discretion?
-
Please clearly list the restrictions necessary.
-
If needed, when is this worker's follow up visit with the LHCP?
-
Please list the date the worker initially returned to work.
-
If applicable, please list the expected date of medical clearance for this worker.
-
Can we accommodate this worker to ensure any injury or illness does not occur again?
-
Please clearly list how we can prevent this incident from occurring again.
