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Series 406.7.1P - Supervisor's Report of Employee Injury

Adopted: July 1980
Revised: August 2013

This form is to be completed for each occurrence of employee injury or work related illness and submitted to the Payroll Department via fax # 651-423-7788 within 24 hours of the incident.

Employee name _________________________________________________ Employee number___________________

Job Title________________________________________________________ School/Building_____________________

Date of incident__________________ Time employee started work________________ Time of incident_ _____________

What date did employee first report injury/illness?_______________________ Reported to________________________

Part(s) of Body Involved (please circle R for right or L for left as appropriate)
❏ abdomen/groin ❏ ankle (R/L) ❏ arm (R/L) ❏ back ❏ chest/rib ❏ ear (R/L) ❏ elbow (R/L)
❏ eye (R/L) ❏ face ❏ finger/thumb ❏ foot/toes (R/L) ❏ forehead ❏ hand (R/L) ❏ head
❏ hip (R/L) ❏ knee (R/L) ❏ leg (R/L) ❏ mouth ❏ neck ❏ nose ❏ side (R/L)
❏ shoulder (R/L) ❏ wrist (R/L) ❏ other _________________________________________________________
Nature of Injury/Illness
❏ abrasion/scratch (skin not broken) ❏ bruise ❏ burn ❏ choking ❏ concussion ❏ dermatitis
❏ dislocation ❏ fracture ❏ hearing ❏ infection ❏ laceration/cut ❏ poisoning
❏ repetitive/cumulative ❏ respiratory ❏ skin punctured ❏ sprain/strain ❏ vision impaired
❏ other _________________________________________________________
Where and How Injury/Incident Occurred
Did injury/incident occur on District 196 property? ❏ yes ❏ no
If yes: What school/building?_______________________________________ Where on property?__________________
If no: Name and address of location: __________________________________________________________________
How did the injury/incident occur and what was employee doing before incident (give details)?______________________
________________________________________________________________________________________________
________________________________________________________________________________________________
Describe the injury/incident in detail: ___________________________________________________________________
________________________________________________________________________________________________
What, if any, tools, equipment, objects or substances were involved?__________________________________________
________________________________________________________________________________________________
Action Taken and Follow Up
What, if any, first aid treatment was given? _ _____________________________________________________________
________________________________________________________________________________________________
Employee: ❏ returned to work within ___ minutes or ___ hours  ❏ left work at __________ and returned __________
(time & date) (time & date)
Did employee go or plan to go to a medical provider? ❏ yes ❏ no If yes, complete the following:
Name of clinic/hospital:___________________________________________
Name of medical provider:________________________________________ Ambulance transport? ❏ yes ❏ no
Address:_ _____________________________________________________ Emergency room visit? ❏ yes ❏ no
_____________________________________________________________ Overnight stay in hospital? ❏ yes ❏ no
Phone:________________________________________________________
______________________________________________________ _________________________________
Witness name and job title Witness phone #
______________________________________________________________ _________________________________
Supervisor or school nurse completing report Date
______________________________________________________________ _________________________________
Principal/administrator signature Date signed
Supervisor's Report of Employee Injury

Procedures/406.7.1P/8-13