SAFETY DIRECTIVE. 2.0 DEPARTMENTS AFFECTED This directive applies to all departments and employees of the Town of Marana.

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1 SAFETY DIRECTIVE Title: Accident Reporting Procedures Issuing Department: Town Manager s Safety Office Effective Date: September 01, 2014 Approved: Gilbert Davidson, Town Manager Type of Action: New 1.0 PURPOSE The purpose of this directive is to assist Town employees with the Town of Marana s policies and procedures for reporting industrial injuries, occupational disease/illness and property damage, and/or motor vehicle accidents. The policies and procedures contained in this section are intended to assist in identifying and complying with regulations and rules set forth by the Occupational Safety and Health Administration (OSHA) Code of Federal Regulations. In all cases where there is a difference between specific OSHA standards and polic i es set forth in this directive, the stricter of the two shall prevail. 2.0 DEPARTMENTS AFFECTED This directive applies to all departments and employees of the Town of Marana. 3.0 REFERENCES 3.1 OSHA Standard 29 CFR Part Recording and Reporting Occupational Injuries and Illnesses 3.2 OSHA Standard Title 29 CFR Part Recordkeeping and Reporting requirements for States that have their own occupational safety and health programs. 3.3 Town of Marana Administrative Directive: Claims Management 3.4 Town of Marana Personnel Policies and Procedures, Policy 4-11, Workers Compensation 3.5 A.R.S. Title 23, Chapter 6 Workers Compensation

2 4.0 DEFINITIONS 4.1 Evaluating p hysician: The p hysician that will complete documenting any injury or illness and the type of medical treatment conveyed. 4.2 First a id i njury: A minor injury ( other than to the back or eye ) in wh ich an employee is self-treated or receives first aid treatment from a fellow employee, and the injury is not deemed serious enough to be evaluated or treated by the Town s provider. 4.3 Industrial i njury: A n injury arising out of, and in the course of, employment. Coincidence of not feeling well during working hours does not automatically qualify as an industrial injury. An i ndustrial i njury is documented on the Employee Injury/Incident Report Form, Attachment A. 4.4 Motor v ehicle: A ny piece of motorized equipment o perated in the public right-of- way or on private property. 4.5 Motor v ehicle a ccident: A n event involving a motor vehicle, such as a single vehicle accident or collision between two or more motor vehicles that occurs on the public rightof-way or on private property. A motor vehicle accident is documented on the Damage to/loss of Town Property Form 7.1 and/or Damage to Personal Property /Injury to Person Form Incident Report, both of which are included in the Town of Marana Administrative Directive: Claims Management. 4.6 Occupational d isease/ i llness: A n occupational disease/illness is a physical condition which is due to an exposure related to a particular trade, occupation, process, or employment, and not ordinary infectious diseases to which the general public are exposed. An Occupational Disease/Illn ess is documented either on the Report of Significant Work Exposure to Bodily Fluids or Other Infection Material Attachment D, or Reporting Employee Exposure to a Chemical Substance Attachment E. 4.7 Public i njury r eport: A n event such as a motor vehicle accident where injuries occur to members of the general public and/or Town employees, or a circumstance where a member of the general public is injured on Town property. Injuries to members of the general public are documented on the Damage to Personal Property/Injury to Person Form Incident Report included in the Town of Marana Administrative Directive: Claims Management. Injuries to Town employees are documented on the Employee Injury/Incident Report Form, Attachment A. 4.8 Property d amage a ccident: A n event that damages private property as the result of an action by a Town employee, or an event that causes damage to Town property, as the result of an action by the general public. A p roperty d amage a ccident is documented on the Damage to/loss of Town Property Form 7.1 or Damage to Personal Property / Injury to Person Form Incident Report included in the Town of Marana Administrative Directive: Claims Management. 4.9 Serious i njury/ i llness: A n injury that requires transport away from the job site and treatment by a medical care professional such as the U. S. Health Works or an e mergency room physician. 2

3 5.0 POLICIES AND PROCEDURES 5.1 Education and Training The Human Resources Department and/or Legal Department shall provide education and training for Departments on the reporting and documentation policies and procedures contained in this directive Town Manager s Safety Office shall provide education and information on fatality and serious injury reporting to conform to OSHA Standards. 5.2 Report of Employee Injury Employees shall immediately report any job-related accident, illness or injury, regardless of severity, to their immediate supervisor. If the employee s immediate supervisor is not available, or if the employee s immediate supervisor is the employee s Department Head, the employee shall report the accident, injury or illness to the employee s Department Head The employee s supervisor or Department Head shall ensure that the accident, injury or illness is reported to the Human Resources Department no later than the next business day In addition, employees shall follow the reporting procedures established by the Human Resources Department, to include completing and s ubmitting any required forms, including the following: Employee Injury/Incident Report Form Attachment A Supervisor Injury/Incident Report Form Attachment B Witness Injury/Incident Report Form Attachment C Industrial injuries shall also be reported to the Town s Workers Compensation insurance provider on the forms designated by Human Resources. 5.3 Medical Treatment In cases of medical emergency, 911 shall be called and any necessary medical treatment shall be obtained In cases where there is no medical emergency, but medical attention is required, the employee sh all report to a designated occupational health clinic, such as U.S. Health Works, for treatment When medical treatment is sought, the employee and/or the employee s supervisor shall notify the Human Resources Department and shall advise Human Resources of any work restrictions or release conditions placed upon the employee s return to work. Documentation from the treating physician shall be provided to Human Resources. 5.4 Employee Refusal of Medical Treatment. If the employee refuses the offer of medical treatment or medical evaluation by a physician the s upervisor shall note on both the Employee Injury/Incident Report Form and the Supervisor Injury/Incident Report Form that the Employee refuses medical treatment at this time. The f orm s shall be printed and both the supervisor and employee shall sign this statement. The forms shall be kept 3

4 on file by Human Resources, in the employee s personnel folder, for a period of no less than one year. 5.5 Occupational Illness Reporting The employee shall complete the Report of Significant Work Exposure to Bodily Fluids or Other Infection Material or Reporting Employee Exposure to a Chemical Substance and sign the form for evaluation by an occupational health clinic, such as U.S. Health Works In addition, the Employee Injury/Incident Report Form shall be completed a nd forwarded to Human Resources. 5.6 Report of Motor Vehicle Accident Employees shall immediately report Motor Vehicle Accidents occurring in the public right-of-way to 911, identifying themselves as a Town employee, operating a Town vehicle. Employees will then contact s upervision to report the accident. The employee will remain on-site (unless they require medical treatment) until the Motor Vehicle Accident is documented by the responding legal authority. Citation for any Motor Vehicle Accident shall be reported to supervision by the next working day Motor Vehicle Accidents that occur on private property shall be immediately reported to s upervision and employees shall remain on-site until the Motor Vehicle Accident is documented by the responding authority or legal jurisdiction. 5.7 Employee Death and/or Catastrophic Injuries. Death of an employee or injuries that occur from any one event that require the hospitalization of two or more employees shall be immediately (within one hour) reported to the Human Resources Department (520) and Town Manager s Safety Office by telephone ( 520 ) or (520) ; 8am-5pm M-F. For events that occur after hours, weekends and holidays, the supervisor in charge will call Community Relations PIO ( 520 ) and request that immediate notification be made to the appropriate Departments. 6.0 RESPONSIBILITIES 6.1 The Safety Coordinator has overall responsibility for the Town s safety programs. The Safety Coordinator shall consult with the Town Manager regarding appropriate changes and amendments to this administrative directive. 6.2 Department Heads, managers and supervisors are responsible for ensuring that the requirements of this directive are fully implemented in their work areas. 6.3 The Department Head of each Department shall be responsible for ensuring that accidents and injuries are reported and investigated in a timely manner. The Department Head shall commit the necessary resources in order to effectively control the hazards identified by an accident investigation or safety inspection. 6.4 Lead personnel such as s upervisors shall be responsible for investigating the causes of all work-related accidents and injuries or illnesses. Supervision shall complete the appropriate forms(s), forwarding the completed forms to Human Resources at (520) and/or Town Clerk at (520) office or (520) fax and shall print out Property Damage Accident forms and ensure that the findings are documented on the 4

5 appropriate forms as set forth in this directive. 6.5 Supervisors shall ensure that any hazards under the Town s control and identified as contributing to any accident are effectively controlled. This shall include ensuring that employees are trained to recognize hazards and know how to take necessary steps to control such hazards. 6.6 Employees are responsible for attending all mandatory training classes, and understanding the policies and procedures outlined in this directive, as well as all Town health and safety procedures. 6.7 Human Resources shall process all claims resulting from employee injury or illness. 6.8 Town Clerk at (520) office or (520) fax shall be responsible for processing all claims regarding Property Damage and Motor Vehicle Accidents and Public Injury. 6.9 The Safety Coordinator and the Safety Committee are authorized to halt any operation of the Town where there is danger of serious personal injury. 7.0 ATTACHMENTS 7.1 Attachment A - Employee Injury/Incident Report Form 7.2 Attachment B - Supervisor Injury/Incident Report Form 7.3 Attachment C Witness Injury/Incident Report Form Attachment D - Report of Significant Work Exposure to Bodily Fluids or Other Infection Material 7.6 Attachment E - Reporting Employee Exposure to a Chemical Substance 5

6 Attachment A TOWN OF MARANA EMPLOYEE INJURY/INCIDENT REPORT FORM THIS FORM IS TO BE COMPLETED BY THE EMPLOYEE AND FORWARDED TO THE EMPLOYEE S SUPERVISOR AS SOON AS POSSIBLE AFTER THE INJURY. If additional space is required, use the back of the form. DEPARTMENT: 1. PRINT NAME OF AFFECTED EMPLOYEE: 2. DATE AND TIME OF INJURY/INCIDENT : 3.WHAT TIME DID YOU BEGIN WORK? 4.DESCRIBE HOW THE INJURY/INCIDENT OCCURRED: (Include location, equipment involved, job duty performing, and details to fully explain) 5. WHAT WERE YOU DOING JUST BEFORE THE INCIDENT OCCURRED? 6. PROVIDE NAMES OF ALL WITNESSES AND ANY OTHER PERTINENT INFORMATION: 7. DESCRIBE THE NATURE OF YOUR INJURY (Include specific body parts, etc): 8. NAME AND LOCATION OF TREATMENT PROVIDER: 9.HAVE YOU PREVIOUSLY HAD A SIMILAR INJURY AND/OR AN INJURY TO THE SAME BODY PART? PLEASE EXPLAIN: 10.FURTHER INFORMATION YOU WOULD LIKE TO INCLUDE REGARDING YOUR INJURY/INCIDENT, INCUDING HOW THIS COULD HAVE BEEN AVOIDED: I CERTIFY THE ABOVE STATEMENTS ARE TRUE TO THE BEST OF MY KNOWLEDGE EMPLOYEE S SIGNATURE and DATE HR/Workers Compensation/2012 6

7 Attachment B TOWN OF MARANA SUPERVISOR INJURY/INCIDENT REPORT FORM THIS FORM IS TO BE COMPLETED BY THE SUPERVISOR AND FORWARDED TO HUMAN RESOURCES WITH THE EMPLOYEE AND WITNESS FORMS WITHIN 24 HOURS OF THE INJURY. IF THE SUPERVISOR WAS NOT AT THE SCENE OF THE INJURY, THEY SHOULD CONTACT ANY EMPLOYEES WHO WERE ON SCENE FOR DETAILS OF THE INJURY/INCIDENT. WITNESSES SHOULD COMPLETE THE WITNESS ACCIDENT REPORT FORM. If additional space is needed, write on back of form. DEPARTMENT: 11. NAME OF AFFECTED EMPLOYEE AND JOB TITLE: 12. DATE AND TIME OF INJURY: 13. IF PRESENT, DESCRIBE WHAT YOU OBSERVED REGARDING HOW THE INJURY/INCIDENT OCCURRED: (Include location of accident/incident, equipment involved, job duty performing, and details to fully explain) If not present, provide details as told to you by witnesses. 14. WHAT IS THE EMPLOYEES DAILY SCHEDULE? (example Monday through Friday 7:00 am through 3:00 pm) 15. PROVIDE NAMES OF ALL WITNESSES (INCLUDING YOURSELF) AND ANY OTHER PERTINENT INFORMATION: 16. DESCRIBE WHAT ACTS/FAILURE TO ACT OR OTHER CONDITIONS CONTRIBUTED TO THIS INJURY/INCIDENT: 17. DESCRIBE WHAT THE EMPLOYEE WAS DOING RIGHT BEFORE THE ACCIDENT: 18. NAME AND LOCATION OF TREATMENT PROVIDER: 19. WHAT ACTION WILL BE TAKEN TO PREVENT REOCCURENCE: 20. FURTHER INFORMATION YOU WOULD LIKE TO INCLUDE REGARDING THE INJURY/INCIDENT: I CERTIFY THE ABOVE STATEMENTS ARE TRUE TO THE BEST OF MY KNOWLEDGE SUPERVISOR SIGNATURE and DATE SIGNATURE and DATE Forms to complete: SW Risk Report of Industrial Injury Employee Incident Injury Report MANAGER Supervisor Injury Incident Report Witness Incident Injury Report (If Applicable) HR/Workers Compensation/2012 7

8 Attachment C Town of Marana WITNESS INJURY/ INCIDENT REPORT FORM THIS FORM IS TO BE COMPLETED BY THE WITNESS TO AN INJURY/ACCIDENT AND FORWARDED TO THE EMPLOYEE S SUPERVISOR WITHIN 24 HOURS OF THE INJURY DEPARTMENT: 21. NAME OF AFFECTED EMPLOYEE AND JOB TITLE: 22. DATE AND TIME OF INJURY/INCIDENT: 23. PROVIDE DETAILS OF WHAT YOU WITNESSED: (Include your location to the employee injured, equipment involved, job duty performing, and details to fully explain) 24. PROVIDE NAMES OF ALL OTHER WITNESSES AND ANY OTHER PERTINENT INFORMATION: 25. FURTHER INFORMATION YOU WOULD LIKE TO INCLUDE REGARDING THE INJURY/INCIDENT: I CERTIFY THE ABOVE STATEMENTS ARE TRUE TO THE BEST OF MY KNOWLEDGE PRINT WITNESS NAME WITNESS SIGNATURE and DATE HR/Workers Compensation/2012 8

9 Attachment D Report of Significant Work Exposure to Bodily Fluids or Other Infectious Material (This form is not a claim form, but a report of exposure. Forms to report a claim to the Industrial Commission are available at: 1. Exposed Employee Birth Date Job Title Last Name First M.I. 2. Address Phone No. 3. Employer s Full Name 4. Employer s Address 5. Date of Exposure Time of Exposure A.M. P.M. 6. Address or Location of Exposure 7. Describe the circumstances surrounding the exposure, including (if applicable) personal protective equipment worn and the names of any witnesses to the exposure (be specific) 8. What were you exposed to? (Directly or indirectly via bandages, personal items, etc.) Check all that apply. Blood Vaginal fluid Broken skin Urine Any other fluid(s) containing blood or infectious material Semen Surgical fluid(s) Mucous membrane Feces Airborne/Respiratory/Oral Secretions Other (specify): Saliva Vomitus Skin infection (e.g. abscesses, boils, or pus-filled/red/swollen/painful skin lesions) 9. Source person(s) information Unknown Known Name DOB Phone No. Address Town State Zip 10. What part(s) of your body was exposed to bodily fluids/infectious material? Did exposure take place through your skin or mucous membrane (be specific)? 11. Did you have any open cuts, sores, rashes, or other breaks/ruptures in your skin or mucous membrane that were exposed to bodily fluids/infectious material (please describe)? I HAVE GIVEN THIS FORM TO MY EMPLOYER AND HAVE RECEIVED A COPY OF THIS COMPLETE FORM. EMPLOYEE SIGNATURE DATE Other Required Steps to Establish Prima Facie Claim for HIV, AIDS or Hepatitis C (A.R.S , -03; A.A.C. R ) 1. You must file this report with your employer no later than ten (10) days after your exposure. 2. You must have blood drawn no later than ten (10) calendar days after exposure. 3. You must have blood tested for HIV or Hepatitis C by Antibody Testing no later than thirty (30) calendar days after exposure and test results must be negative. 4. You must be tested or diagnosed as HIV positive no later than eighteen (18) months after the exposure, or tested and diagnosed as positive for the presence of Hepatitis C within seven (7) months after the exposure. 5. You must file a workers compensation claim with the Industrial Commission of Arizona no later than one (1) year from the date of diagnosis or positive blood test if you wish to receive benefits under the workers compensation system. Other Required Steps to Establish Prima Facie Claim for MRSA (A.R.S ; A.A.C. R ) 1. You must file this report with your employer no later than thirty (30) days after your exposure. 2. For a claim involving MRSA, you must be diagnosed with MRSA within fifteen (15) days after you report in writing to your employer the details of the exposure. 3. You must file a workers compensation claim with the Industrial Commission of Arizona no later than one (1) year from the date of diagnosis if you wish to receive benefits under the workers compensation system. Other Required Steps to Establish Prima Facie Claim for Spinal Meningitis or TB (A.R.S ; A.A.C. R ) 1. You must file this report with your employer no later than ten (10) days after your exposure. 2. For a claim involving spinal meningitis, you must be diagnosed within two (2) to eighteen (18) days of the possible significant exposure and for a claim involving tuberculosis; you must be diagnosed within twelve (12) weeks of the possible significant exposure. 3. You must file a workers compensation claim with the Industrial Commission of Arizona no later than one (1) year from the date of diagnosis if you wish to receive benefits under the workers compensation system. Employer: Keep Original (Notify Carrier) Employee: Keep Copy THIS FORM APPROVED BY THE INDUSTRIAL COMMISSION OF ARIZONA REV. 7/11 9

10 Attachment E Employee Exposure to Chemical Substance Name Employee No. Department Location of Exposure Date/Time Reported Date/Time of Incident Employee Description of Chemical Exposure (to be completed by employee): Employee s Signature Samples Taken Yes No Results Attached Yes No MSDS Attached Yes No Supervisor s Signature Print Name and Date Supervisor signature indicates permission for Physician Evaluation THIS IS AN EMPLOYEE S REPORT OF A CLAIMED EXPOSURE; IT DOES NOT CONSTITUTE AN ADMISSION BY THE TOWN THAT SUCH EXPOSURE OCCURRED 10

11 REVISION HISTORY REV DESCRIPTION OF CHANGE DATE OR Original Release 09/01/2014 Caution : A copy of this Administrative Directive is an uncontrolled document. It is your responsibility to ensure you are using the current version. The electron ic version is the only acceptable and controlled Administrative Directive. 11