Information
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Reporting location:
- ANNA BOYD SCHOOL
- BETHEL-HANBERRY ELEMENTARY SCHOOL
- BLYTHEWOOD ACADEMY
- BLYTHEWOOD HIGH SCHOOL
- BLYTHEWOOD MIDDLE SCHOOL
- BOOKMAN ROAD ELEMENTARY SCHOOL
- BRIDGE CREEK ELEMENTARY SCHOOL
- BUS - KILLIAN HUB
- BUS - ACTIVITY
- BUS - TRAINING
- CAP PROGRAM
- CATAWBA TRAIL ELEMENTARY SCHOOL
- CENTER FOR ACHIEVEMENT
- CENTER FOR INQUIRY
- CENTER FOR KNOWLEDGE
- CENTER FOR KNOWLEDGE - NORTH
- CLEMSON RD. CHILD DEV. CENTER
- DENT MIDDLE SCHOOL
- DISTRICT OFFICE
- E L WRIGHT MIDDLE SCHOOL
- FOREST LAKE ELEMENTARY SCHOOL
- JOSEPH KEELS ELEMENTARY SCHOOL
- KELLY MILL MIDDLE SCHOOL
- KILLIAN ELEMENTARY
- LANGFORD ELEMENTARY
- LONGLEAF MIDDLE SCHOOL
- LONNIE B NELSON ELEMENTARY SCHOOL
- LOUIE W CONDER ELEMENTARY SCHOOL
- MULLER ROAD MIDDLE SCHOOL
- NORTH SPRINGS ELEMENTARY SCHOO
- POLO ROAD ELEM SCHOOL
- PONTIAC ELEMENTARY SCHOOL
- RICE CREEK ELEMENTARY SCHOOL
- RICHLAND NORTHEAST HIGH SCHOOL
- RIDGE VIEW HIGH SCHOOL
- ROUND TOP ELEMENTARY SCHOOL
- SANDLAPPER ELEM SCHOOL
- SPEARS CREEK ROAD CHILD DEVELOPMENT CTR
- SPRING VALLEY HIGH SCHOOL
- SUBSTITUTE
- SUMMIT PARKWAY MIDDLE SCHOOL
- SUPPORT SERVICE CENTER
- WESTWOOD HIGH SCHOOL
- WINDSOR ELEMENTARY SCHOOL
- WR ROGERS ADULT CONTINUING & TECH ED CTR
- BUS - SP. NEEDS
- BUS - RNE HUB
- LAKE CAROLINA ELEMENTARY LOWER
- LAKE CAROLINA UPPER
- SSC-MAINTENANCE
- SSC-SECURITY
Employee Information
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Name of Employee:
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Date of Report:
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Occupation:
- ABA LINE THERAPIST
- ACCOUNTANT
- ACCOUNTING STAFF
- ADMINISTRATIVE ASSISTANT
- ADMINISTRATIVE MONITOR
- ADMINISTRATIVE TECHNOLOGY SPEC
- ASSIST. EMERGENCY SERVICES MGR
- ASSISTANT ADMINISTRATOR
- ASSISTANT PRINCIPAL
- ATHLETIC DIRECTOR
- AUDIOLOGIST
- AUDITORIUM TECH. MGR/DIR
- BENEFITS MANAGER
- BENEFITS REPRESENTATIVE
- BOOKKEEPER
- BUS DRIVER - ADULT
- BUS DRIVER - PART TIME
- BUS MONITOR FOR HANDI - P/T
- CAFETERIA MANAGER
- CAFETERIA WORKER
- CAREER DEVELOPMENT FACILITATOR
- CAREER INFO SPECIALIST
- CATE TEAM LDR
- CHIEF ACADEMIC OFFICER
- CHIEF FINANCIAL OFFICER
- CHIEF HUMAN RESOURCES OFFICER
- CHIEF PLANNING OFFICER
- CLERICAL AIDE
- COMMUNICATIONS COORD
- CONSULTANT
- COORD. OF INTERVENTION PROG.
- COORD. SPECIAL ED. COMPLIANCE
- COORDINATOR - SCHOOL TO WORK
- COORDINATOR-GEAR UP
- COORD-SUPERINTENDENT'S OFFICE
- CURRICULUM COORDINATOR
- CUSTODIAL WORKER
- DATA ANALYST
- DATA COORDINATOR
- DEPUTY SUPERINTENDENT
- DIR OF ACADEMIC INITIATIVES
- DIR. OF ACCOUNTABILITY & EVAL.
- DIR.CLASS.PERSONNEL & EMP SVCS
- DIRECTOR OF FINANCIAL SERVICES
- DIRECTOR OF INFORMATION TECH
- DIRECTOR OF STUDENT SERVICES
- DIRECTOR OF TEACHER QUALITY
- DIRECTOR PSYCHOLOGICAL SERVICES
- DIST FOREIGN LANG LIAISON
- ELEMENTARY TEAM LDR
- EMERGENCY SERVICES MANAGER
- ENERGY/MAINTENANCE ASSISTANT
- EQUIPMENT TECHNICIAN
- ERP COORDINATOR
- ERP SUPPORT ANALYST
- EVENTS & SPEC RECOGNITIONS MGR
- EXEC. DIR. COMMUNICATIONS/STRAG
- EXECUTIVE DIR. ADMINISTRATIVE SERVICES
- EXECUTIVE DIR. CURRICULUM, INST & PD
- EXECUTIVE DIR. OF OPERATIONS
- EXECUTIVE DIR. PERSONNEL SVCS
- EXECUTIVE DIR. SPECIAL SVCS
- GIS-DATA SPECIALIST
- GRANTS WRITER/COORDINATOR
- GUIDANCE COUNSELOR
- HEAD CUSTODIAN I
- HEALTH AIDE
- INSTRUCTIONAL AIDE
- INTERVENTION SPECIALIST
- IT PROJECT RESOURCE ASST
- LAN SUPPORT TECHNICIAN I
- LEAD SOCIAL WORKER
- MAINTENANCE WORKER III
- MAINTENANCE WORKER V
- MEDIA PRODUCER
- MEDIA PRODUCTION MANAGER
- MEDIA SPECIALISTS
- OCCUPATIONAL THERAPIST
- PARENT EDUCATOR
- PATROL SUPERVISOR
- PHYSICAL THERAPIST
- PHYSICAL THERAPIST ASSISTANT
- PRINCIPAL
- PSYCHOLOGIST COORDINATOR
- ROTC INSTRUCTOR
- SCHOOL NURSE
- SCHOOL PSYCHOLOGIST
- SECRETARY
- SECURITY STAFF
- SOCIAL WORKER
- SPECIAL EDUCATION AIDE
- TEACHER
- TEACHER AIDE
- TEACHER CURRICULUM
- TEACHER SPECIALIST
- TEACHER-COACH
- TEACHER-IT SPECIALIST
- TEACHER-MAGNET DIR.
- TEST & TUTORING MONITOR
- THEATRE TECHNICIAN
- TRANSPORTATION
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Dept:
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Age:
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Length of Employment:
Accident Information
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Date and time of Accident:
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Exact Location:
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Description of Accident- What was Employee doing?
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What tools or equipment was he/she using?
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Witnesses- Names/What they saw or heard and when:
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Describe extent of Employee's injury:
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When did Employee report the Accident? Date/Time
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Did Employee go to a doctor for treatment?
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At what doctor's location did they go for treatment?
- Palmetto Urgent Care
- Palmetto Health Works
- First Care
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Did Employee go to a hospital?
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What hospital did they go for treatment?
- Palmetto Richland
- Palmetto Baptist
- Palmetto Baptist
- Other
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If "Other" list name of hospital.
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Did the Employee return to work after the accident? When?
Accident Information and Follow-up
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After investigating this accident, was this caused by an unsafe act or unsafe condition?
- Unsafe Act
- Unsafe Condition
- Other
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If the answer to preceding question is “Other” please explain.
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What should be done, and by whom, to prevent this accident from recurring in the future?
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What are you doing to see that this is done?
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Were pictures / videos retrieved and turned in?
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Please include pictures of the accident scene.
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Signature:
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Title
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Date:
