Employee Instructions for Work-Related Injury or Illness

The following information is provided to guide the employee who is injured while at work.
It is important that these instructions be followed in order to receive all available benefits. If possible, provide a verbal description of the accident to your supervisor, immediately after the accident.

Medical Treatment

Injured while on site:

If you are injured while on duty and need medical attention, it is recommended that you go to your nearest emergency room. Your supervisor will provide you with all the necessary forms to report the accident.

Injured while off site:

If you are injured while off campus, please contact your immediate supervisor first. Then contact your Human Resources Director (936-598-6315 ext. 13) (Available 24/7) so that a report can be filed and a claim number can be issued to the hospital of your choice.

Immediately following your initial treatment complete the incident report form and forward it to your supervisor.

IMPORTANT: Any medical treatment other than emergency visits, initial treatments, or routine office visits must be pre-authorized.

Your medical provider will ask you for a “claim number” and insurance information. So please make sure you contact your immediate supervisor and your Human Resource Director at the number provided.

You will have to provide all medical documents to your HR Department.

Please fax to: 936-598-7273.

Note: If you do not complete and submit the injury report, you may be billed for any services rendered.

Supervisor’s Instructions for Reporting a Work-Related Injury

Get as many details as possible about the incident from the employee and witness (es) Collect the completed Employee’s Report of Work-Related Injury Form and Accident
Witness Statement. (These forms must be completed by the employees) Complete the Supervisor’s Report of Work-Related Injury Form and return all forms within 24 hours to:

Human Resources Director cleary@tricountycommaction.org Fax: 936-598-7273

Report the number of days lost from work and/or the number of days employee is working with restrictions. If the information is not available at the time of completing the report, call the Human Resources Director (936-598-6315 ext. 13) when the employee returns to work or is no longer working with restrictions. (Please make sure that employee has a full release from the doctor before allowing them to return to work.)When an employee is absent due to an on-the-job injury, the supervisor must require medical documentation for their absences. These days are not considered sick pay and are not in the same guidelines of our sick pay policy. Medical documentation is required needed for the Insurance Claim Report.

This medical documentation should contain:
Diagnosis
Restrictions
A return to work date
Release to “full duty”

If the employee is returned to work in a modified duty capacity, the supervisor should make every effort to accommodate the restrictions,

ACCIDENT WITNESS STATEMENT TRI-COUNTY COMMUNITY ACTION, INC.

(To be completed within 24 hours of the accident)

Name of injured employee: _________________________________________________________

Department: __________________________ Job Title: ________________________________

Location of accident: ____________________________________________________________
Bldg. Area (hallway, office, parking lot)
Date of accident: __________________ Time of accident: ______________________________

Describe in detail how the accident occurred:
______________________________________________________________________________

______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
(Describe what employee was doing, how the accident occurred,