Investigation and SignSheets Blank

ACCIDENT / INJURY INVESTIGATION CHECK-LIST REPORT # 757
CLIENT INFORMATION
REPORT DATE:
MAGNUM LOCATION:
LOCATION OF INJURY:
CLIENT NAME:
DEPARTMENT:
CLIENT ADDRESS:
CITY:
STATE:
ZIP CODE:
EMPLOYEE INFORMATION
NAME OF EMPLOYEE: LAST
FIRST
MIDDLE
EMPLOYEE ADDRESS:
CITY:
STATE:
PHONE NUMBER:
SEX:
AGE:
OCCUPATION OR JOB TASK AT TIME OF INCIDENT:
SOCIAL SECURITY NUMBER:
ZIP CODE:
DATE OF HIRE:
WAS THIS THE REGULAR OCCUPATION OF EMPLOYEE? WAGES PER HOUR?
INCIDENT INFORMATION
DATE AND TIME OF INJURY:
DATE AND TIME EMPLOYEE NOTIFIED
CLIENT:
EMPLOYEE'S SUPERVISOR AT TIME OF INCIDENT:
TELEPHONE NUMBER:
DATE AND TIME EMPLOYEE NOTIFIED MAGNUM STAFFING:
DID SUPERVISOR WITNESS INCIDENT?
WITNESS NAME:
ANY OTHER WITNESSES?
Witness Phone Number
INJURY DESCRIPTION
PART OF BODY INJURED OR AFFECTED (NOTATE RIGHT OR LEFT WHERE APPLICABLE):
ABDOMEN
ANKLE
CHEST
ELBOW
EYE
FINGER
FOOT
FOREARM
HAND
HIP
JAW
KNEE
LOWER BACK
LOWER LEG
MOUTH
NECK
NOSE
PELVIS
SHOULDER
SKULL, SCALP
SPINE
THIGH
TOE
UPPER ARM
UPPER BACK
WRIST
OTHER:
NATURE OF INJURY OR ILLNESS:
ABRASION
AMPUTATION
BRUISE / CONTUSION
BURN
CHEMICAL EXPOSURE
DISLOCATION
FRACTURE
HEAT / COLD STRESS
INFECTION
IRRITATION
LACERATION
PUNCTURE
RESPIRATORY
SKIN DISORDER
MUSCLE STRAIN /
SPRAIN
OTHER:
TREATMENT INFORMATION
MEDICAL PHYSICIAN OR FACILITY:
ADDRESS OF PHYSICIAN OR FACILITY:
Physician Phone Number
CITY:
STATE:
ZIP CODE:
By signing below, I certify that the above named physician or facility is my choice for medical treatment for the injury as reported
above.
EMPLOYEE SIGNATURE:
DATE:
INCIDENT DESCRIPTION IN DETAIL
WHAT CONDITIONS, TOOLS, OR EQUIPMENT CONTRIBUTED TO THIS INCIDENT?
SAFETY EQUIPMENT PROVIDED:
BACK BRACE
BOOTS
WAS IT IN USE AT THE
TIME OF INCIDENT?
GLOVES
HARD HAT
SAFETY GLASSES
OTHER (Explain?)
MAGNUM STAFFING INVESTIGATOR'S DESCRIPTION OF INCIDENT & COMMENTS:
CORRECTIVE ACTION TAKEN:
SIGNATURES
To be signed by the employee: I have reviewed the information contained in this report and verified the accuracy of the
information as reported by myself.
EMPLOYEE SIGNATURE:
MAGNUM STAFFING INVESTIGATOR:
DATE::
MAGNUM STAFFING INVESTIGATOR SIGNATURE:
DATE::
RETURN TO WORK INFORMATION
To Employee: It is our policy at Magnum Staffing Services to work together with an injured worker so that he/she can return to
work as soon as possible. If your doctor does not release you to full duty immediately following your injury, a light duty job will be
designed around the limitations or restrictions placed by your medical provider. This light duty assignment will be paid at the
same wage paid to you at the time of injury. The light duty assignment will terminate when you are released by the medical
provider to full duty without restrictions.
To be signed by the Employee: I, ________________________________________________________________________
have been offered a light duty assignment through Magnum Staffing Services and agree to report to the Magnum Staffing
Services office following release to light duty by the medical provider. I understand that failure to report for light duty or full duty
following the release by the medical provider will result in possible suspension and/or termination by Magnum and may possibly
terminate any benefits under Texas Workforce Compensation laws.
EMPLOYEE SIGNATURE:
WITNESS:
AUTHORIZATION FOR MEDICAL RECORDS AND REPORTS
TO WHOM IT MAY CONCERN:
I hereby authorize you to furnish MAGNUM STAFFING SERVICES or its representative all
medical information you have concerning ________________________________________ with
respect to illnesses, injuries, medical histories, consultations, prescriptions, treatment including
x-ray films and copies of all hospital and medical records.
A photo static copy of this authorization will be considered as effective and valid as the
original.
Your assistance and cooperation will be appreciated.
Dated this ____________________ day of _______________________________, 20_____
Signature _________________________________________________________________
REFUSAL OF MEDICAL TREATMENT
I __________________________________ INCURRED AN ON THE JOB INJURY
ON
_____ / ______ / _____ AT _________________________________ AT
________
(AM / PM)
I HAVE BEEN OFFERED MEDICAL TREATMENT BY MAGNUM STAFFING SERVICES
PER COMPANY POLICY IMMEDIATELY AFTER THE INCIDENT. I AM REFUSING THE
TREATMENT ON MY OWN JUDGEMENT AND DUE HEREBY RELEASE MAGNUM
STAFFING SERVICES, THE CLIENT, AND ALL OTHERS INVOLVED IN SAID ACCIDENT
OF ANY LIABILITY.
________________________________________________
EMPLOYEE SIGNATURE
________________________________________________
WITNESS
WITNESS STATEMENT
Date: _________________________________
Name: ________________________________
DESCRIPTION OF INCIDENT
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
__________
Witness Signature: ______________________________________________
Magnum Staffing Member (Other): _________________________________
MAGNUM STAFFING INVESTIGATOR STATEMENT
Date: _________________________________
Name: ________________________________
DESCRIPTION OF INCIDENT
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
__________
Magnum Staffing Investigator: _________________________________
Magnum Staffing Services, Inc.
2900 Smith St Suite 250
Houston
(713) 658-0068
TX
77006