Appendix B(2) EMPLOYEE INJURY REPORT

Supervisor's Workers' Compensation Responsibilities
Eastern Mennonite University has adopted the following policies to define your responsibility as the SUPERVISOR of an employee (including work study students) who has been injured or is ill due to his/her work duties:

1. Provide a safe and healthful working environment for those you supervise and encourage safe work practices.  The Chemical Hygiene Officer will be happy to assist you; if you have questions, please call x 4420.
2. If an employee you supervise is injured on the job and/or has a job-related illness:
   1. Send the employee for medical treatment.  If it is a minor injury send the employee to the EMU Health Services.  If the EMU Health Services is not available contact RMH Center for Corporate Health (540-564-5622) during normal working hours.  If an employee you supervise is BADLY injured outside of normal working hours and needs EMERGENCY medical treatment, send or take him/her to Rockingham Memorial Hospital's emergency room.
   2. After the employee has received medical treatment, give him/her an Accident Report form for Workers' Compensation (Appendix B (2)) to complete, and assist him/her if necessary.
   3. Inform the Human Resources Office of the accident immediately after the incident. The Human Resources Office must contact the insurance company as soon as possible after the injury.  When the employee returns the accident report to you, check to make sure each question has been answered COMPLETELY and forward the form to the Human Resources Office.
   4. If the employee misses work because of the injury or illness, report the date he/she returns to work to the Human Resources Office.  The employee must obtain a WORK EXCUSE from the attending physician for all the days lost in connection with the injury.  If an employee takes unauthorized leave from work it will be listed as sick or annual leave.
   5. Forward medical bills received by the employee for the medical treatment to the Human Resources Office.  The employee should not pay for the medical treatment.
   6. It is imperative that SUPERVISORS inform employees of their rights and responsibilities in connection with EMU Workers' Compensation procedures before and at the time of the injury.
   7. University employees who are injured on the job must complete the "Accident Report for Workers' Compensation Claim."  An example is attached as B (2).  Students who are injured on our premises need to report the incident to the professor responsible for the area where the accident occurred.  The accident is also to be reported using the prescribed "Non-Employee Injury Report Form."  An example is attached as Appendix B(3).
   8. Attempt to remedy the situation which caused the accident.
3. For further information or questions regarding EMU's Workers' Compensation Program call the Human Resources Office at ext. 4049.

 
 
EMU Chemical Hygiene and Safety Plan Appendix B(2)
EMPLOYEE INJURY REPORT
(First Report of Accident)
Instructions:
1. Complete the form promptly (in ball-point pen) for incidents involving injury or potential injury.
2. Return completed form to the Human Resources Office
Date Reported: ________________
This report was prepared by:
(Print Name and Title)
EMPLOYEE INFORMATION
Name: Date of Birth:
Address: Phone #:
Male Female Full-Time Part-Time Social Security#: - -
Married Single # of Dependents
Length of time at current job: years months
Nature of duties:
NATURE AND CAUSE OF ACCIDENT
Date of Injury: Time of Injury: a.m. p.m.
Date of incapacity: Time incapacity began: a.m. p.m.
Describe fully how injury or illness occurred (e.g. slip/fall, lifting, chemical):




Cause of accident (specify if machine, tool, or object causing injury or illness):
Part of body injured (e.g. forehead, neck, right arm, left leg):
Nature of injury (e.g., fracture, sprain, laceration):
Equipment, material or substance involved:
Were safeguards provided? _____ yes _____ no Were safeguards used? _____ yes _____ no
Description of safeguards:
If motor vehicle accident, driver's license #: State where issued:
Contributing factors:
If other parties involved: (name, address, phone):

Witness information: (name, address, phone):

Was the accident on employer's premises? _____ yes _____ no
Did employee lose any time from work? _____ yes _____ no
Is the employee back at work? _____ yes _____ no If yes, date returned:_________________________
Was employee paid for date of injury? _____ yes _____ no
TREATMENT
First aid What type of first aid was administered? 1st day of treatment:
Who administered first aid?
___Hospital/Clinic (name, address, phone #{_}):
Treatment: Length of stay: 1st day of treatment:
Physician (name, address, phone #):
Treatment: Specialty: 1st day of treatment:
HUMAN RESOURCES OFFICE USE ONLY
Date reported to workers' compensation insurance ________________
Reported as "Incident Only" yes no
EMPLOYEE JOB INFORMATION
Occupation when injured:
Date of hire: Hours worked per day: _________ Days worked per week: _________
Wages per hour: $_________Earnings per week: $_________
Supervisor's name (first, MI, last), Phone #/Ext.:
Scheduled work hours:
ACCOUNT INFORMATION
Human Resource: Human Resources
Employer's Name and Address: Eastern Mennonite University
1200 Park Road
Harrisonburg, VA 22801 Phone: 540-432-4049
Federal tax ID#:54-0575812
Nature of Business: Education
EMU Chemical Hygiene and Safety Plan