Cherokee County School District Workers Compensation Checklist

Transcription

1 Cherokee County School District Workers Compensation Checklist 1. The employee should complete the Employee Incident Report in their own writing. This document must be completed on site at the time of injury. If it is an emergency situation the administrator should deliver the document to the employee s home or hospital and take it back with them following completion. 2. Using the information on the Employee Incident Report the building administrator or supervisor should complete the Job Related Injury Form 1-A. 3. If there are witnesses every witness named MUST complete the witness statement form. 4. If an incident requires medical treatment, or is serious enough that it might warrant future treatment, please collect any additional evidence available (take pictures, note the time and check security cameras for video, etc.) *** All three forms (Employee Statement, Form 1-A, and Witness Statements) must be completed for each incident. *** If an injury requires medical treatment: 1. Have the employee sign and date the Medical Release form. 2. If deemed necessary, the school can make a doctor s appointment for the employee themselves if they choose, or ask that we make it. 3. Provide the employee with the included Notice to Provider form and tell them to give it to the doctor. If the injury is serious enough to require immediate medical attention provide the same form to the responding Paramedics. 4. Send the complete incident package to the district office before the employee leaves the building unless the injury is serious enough to require emergency attention. If you have to send it without an administrator s signature that is fine. You can always submit the signed version later. Network Provider: MGC Family Medicine Peachview Preferred Physician is Dr. Ruffing 722 Hyatt Street Suite C Gaffney, SC *Note: Urgent Care has not been approved by the SCSBIT for use. Injured employees must continue to visit Dr. Ruffing, or go to the ER if necessary. If you have any questions, please contact Chad Palmer at

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4 Cherokee County School District Employee Job Related Injury Form 1-A (To be completed by Building Administrator/Supervisor) Employee Information Name (Last, First, Middle Initial) Social Security Number Telephone Number Address Occupation School/Department City, State, Zip Number hours worked (day/week) Time Employee Began Work AM PM How long at current position Occurrence/Treatment Location/Department Accident Occurred Date of Accident/Illness Time Incident Occurred Specific activity the employee was engaged in when accident/illness occurred AM PM Type of Injury/Illness Body Part Affected Date/Time Employer Notified Last Date Worked Date Returned to Work Number of Days Missed Due to Injury Describe in Detail Nature of Injury (Include part of body affected, e.g. amputation of right index finger at 2 nd joint, fractured arm, lead poisoning, etc) Describe Employee s Activities when Injury Occurred w/details of How Event Occurred (e.g. Operating drill press, saw, driving tractor, activity on playground, mopping kitchen, etc.) Witness (Name, Address, Telephone Number) Attending Physicians (Name & Address) Please Check if Services Rendered at: MCG- Peachview ( ) 101 Professional Park Gaffney SC Please check here if the Employee has declined medical treatment at this time. Please Check if Services Rendered at: Mary Black Health System Gaffney, SC ( ) 1530 N Limestone St Gaffney SC Please Check if Services Rendered at: (Please list hospital Name, Address and telephone number) I certify that the above information is true and correct Sworn to and subscribed to me before this date Date Employee Name (Please Print) Supervisor Name (Please Print) Employee Signature Date Supervisor Signature

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6 SCSBIT The South Carolina School Boards Insurance Trust Notice to Provider (To be presented to doctor, hospital, or clinic by injured party when reporting for treatment) has reported that he/she was injured in our (Employee name) employment on (date of injury). Please forward all reports and bills to the following address: South Carolina School Boards Insurance Trust Attn: Workers Compensation 1027 Barnwell Street Columbia, SC School Location / Employer Cherokee County Schools Employ er Signature (authorizing treatment) Phone Date Approved Physician for treatment Phone NOTE: This is not an acceptance of liability. Return to Work Notice (To be completed by Doctor after examining employee) Name of Doctor s Office/Clinic Location Phone Diagnosis Employee IS able to return to regular duties at this time. Employee IS able to return to light duties at this time, list limitations: Employee IS NOT able to return to work at this time because: Request Referral to: (if applicable) Follow-up appointment date Signature (Doctor) Date

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