Painters USA Incident/Injury Report

Information

Document No.
Client / Site
Conducted on
Employee Name
Job Site Foreman
Prepared by
Location
What to do in case of an incident/Accident while on a job, on a non-working day.

Vehicle & Accident (If you are Foreman or Supervisor on call)
Foreman should;
Call for help, 9-1-1/Make police report
If victim is taken to the hospital by ambulance, accompany her/him – take your car.
(Out of town jobs) or (at job site)
Speak ONLY to medical personnel, police officers, the customer, other employees, and victim’s family about the injury.
Complete an accident report and submit to the office immediately Via email

(Jbleakley@paintersusainc.com)(Your Field supervisor)(glopez@paintersusainc.com)

(If possible)Take pictures of the accident sight, including surrounding areas.
Supervisor on call,
If taken to the hospital/Find out what hospital and request that a Post-Drug screen be done.
Call and speak to involved employees to make sure they are ok

Grisel, will file claim with Both Assurance & Amerisure as soon as possible & send out updates
As well as follow up with Employees involved in accident.

Personal Injury-No matter how big or how small the injury must be reported to Safety & HR

Injured employee should fill out Incident report and send out to;

(Jbleakley@paintersusainc.com)(Your Field supervisor)(glopez@paintersusainc.com)

Foreman- Upon receiving this report you should contact that employee and make sure they are ok and make sure Incident report is completely filled out. And notify OPS, HR if this person will be taking time off.

Grisel-Will follow up with injured person to get doctors paperwork. And to double check and confirm that employee is doing well.

IMPORTANT FACT TO KNOW
*After three days of being sick doctor’s note is required to return, this is mainly because we need to make sure they are fully capable.*
*(Foreman you must never allow an employee to return to work until having medical clearance)*

Incident/Accident
Foreman-If on the job, together fill out an incident report asking what happened? Where? Do you need to see a doctor? Was anyone else involved? Were there any witnesses?
(Make sure all questions are answered on the report)

Once report is complete email out to ;
(Jbleakley@paintersusainc.com)(YourFieldsupervisor)
(glopez@paintersusainc.com)(dlottes@paintersusainc.com)

If employee is requesting to go see a doctor but not necessarily a Hospital visit on a work day notify Grisel
If not a work day they should be encouraged to visit;

Concentra Medical Center Will County Medical Associates Concentra Medical Center/TX
7421 South Cass Ave. 2100 Glenwood Ave. 2160 E Lamar Blvd
Darien IL, 60561 Joliet IL, Arlington TX,
Hours: Hours: Hours:
Mon/Fri 8AM-8PM Mon-Fri 8AM-430PM Mon-Fri 8am-8pm
Sat/9AM-1PM Phone # 815-741-6267 Sat/Sun 9am-4pm
Phone # (630)286-5300 Fax: 815-741-6262 Phone# (972)988-0441
Fax # (630)986-1096

If employee taken to the hospital, you should go with him/her and request a post-accident drug screen be performed. (So long as you are able to leave the job site)

Field Supervisor, follow up with Foreman to make sure everything is ok/do they need any assistance.
Grisel- Will also reach out to Foreman and employee as a follow up, Depending on severity of incident/Accident Grisel will file a workers comp claim. (And will notify Nicole/Paul/John)

Non-employee Incident, If it happens at our facility we must follow same incident report procedures.

If at a job site,
Attempt to have the non-employee fill out an incident report with you, if the person doesn’t want to talk to us still write it up and have a witness sign off on it. Get as many details about the person as possible.

And send out to For notification purposes.
(Jbleakley@paintersusainc.com)(Your Field supervisor)(glopez@paintersusainc.com) (dlottes@paintersusainc.com)

Incident Details

INJURY (MEDICAL FACILITY TREATMENT REQUIRED)
MINOR INJURY - BASIC FIRST AID (NO MEDICAL FACILITY TREATMENT NEEDED)
ACCIDENT
NEAR MISS INCIDENT
PROPERTY DAMAGE
LOCATION OF INCIDENT
ENTER DATE AND TIME

INCIDENT DESCRIPTION

AUDITOR DESCRIBE HOW THE INCIDENT OCCURRED
AUDITOR SIGNATURE
INJURIED/NEAR MISS EMPLOYEE DESCRIPTION
EMPLOYEE SIGNATURE
WHERE THERE ANY WITNESSES? IF SO LIST THEIR NAMES
WITNESS DESCRIPTION OF WHAT HAPPENED
WITNESS SIGNATURE
WITNESS #2 DESCRIPTION OF WHAT HAPPENED
WITNESS #2 SIGNATURE
WAS THE EMPLOYEE WEARING THE REQUIRED SAFETY GEAR AND FOLLOWING COMPANY SAFETY POLICIES?
WHAT WAS THE NATURE OF THE INCIDENT?(i.e. fall, struck by, slip,trip,)
ADD PICTURES OF THE AREA, EQUIPMENT ETC.....
HOW/WHY DID THIS HAPPEN?
WHAT CAN BE DONE TO PREVENT RE-OCCURRENCE?