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OFFICIAL OCCUPATIONAL INJURY/ILLNESS REPORT

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OFFICIAL OCCUPATIONAL INJURY/ILLNESS REPORT

Revised August 2010

Instructions: All occupational injuries and illnesses are to be reported immediately. This form must be completed within 24 hours after a report of an occupational injury/illness to an employee of the Fauquier County Government or Public Schools, and submitted to Human Resources (Fax

540.422.8318).

Date of Occupational Injury/Illness _________________ Time ____________ AM / PM

Date Reported to Supervisor Time Reported Supervisor

Name of Employee _____________________________________ Work Phone # Home Phone#

Address _______________________________________________________________________________________________________________

Employee ID # ________________________ Sex DOB ______ Department

Body Part(s) Injured ______________________________________________________________

Employment Start Date Time in Present Job

Job Title Supervisor's Name

Location of Accident Task being Performed

Witness Name Phone Witness Name Phone

Was employee paid in full for day of injury? Yes No Hours worked per day_______ Days worker per week ________

Describe how the injury occurred

What caused the accident

What could have prevented this accident

First Aid received Yes No If yes, by whom?

Transported to Health Care Facility Yes No If yes. Where?

Were you using required safety equipment? Yes No

Has employee returned to work? Yes No If yes, what date?

The information I have provided either in my own writing or verbally for the purpose of this form is true and correct. I understand that providing false or misleading information or omission of information on this report or any other form relating to this claim of injury/accident may result in termination of my employment. I have received the Panel of Physicians list. I understand that if I elect not to use a physician on the list I will be responsible for the cost and payment of any medical treatment received. Also, I will be denied worker’s compensation for any absence based on a disability which is not certified by an approved panel physician.

Signature of Employee: _________________________________________ Date: __________

I did/did not (circle one) witness the alleged injury/illness described above.

Name of Supervisor (print)

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*Specialists Panel available upon request. Please contact Human Resources.

Rev. 02/2012

FAUQUIER COUNTY

WORKERS’ COMPENSATION PANEL OF PHYSICIANS

Gregory S. Goulb, MD

Piedmont Family Practice

540-347-4400

Chris Ward, MD

493 Blackwell Road

Shakur Kommu, MD

Warrenton, Virginia 20186

Ash Diwan, MD,

Francis Bourgeois, MD

Warrenton Urgent Care

540-351-0662

75 West Lee Highway

Warrenton,

Virginia

20186

Norris Royston, MD

Countryside Family Practice

540-364-1581

Elizabeth Hoebel, MD

8452 Renalds Avenue

Robert Houska, MD

Marshall, Virginia 20115

Wendy

Adeshina,

MD

Nova

Urgent

Care

540-347-7611

Grace Keenan, MD

528 Waterloo Road

Warrenton,

Virginia

20186

William Simpson, MD

Piedmont Internal Medicine

540-347-4200

Kevin McCarthy, MD

419 Holiday Court, Suite 100

Demetrius Mauory, MD

Warrenton, Virginia 20786

Joseph David, MD, Jae Lee,

MD & Gerhard Kraske, MD

William J. Bender, MD

Amherst Family

Practice

540-667-8724

Harry Gustin, III, MD

867 Amherst Street

Jefferson Livermon, MD

Winchester, Virginia 22601

Patricia Houser, MD, & Lora Gillis, MD

Lawrence

Moter,

MD Pratt

Medical

Center 540-368-7814

Marien Vasquez, MD

12101 Carol Lane

Yasmin

Tarter,

MD

Fredericksburg,

Virginia

22407

THE CLOSEST EMERGENCY FACILITY MAY BE USED IN AN EMERGENCY SITUATION.

ONCE THE EMERGENCY TREATMENT IS COMPLETED A PANEL PHYSICIAN MUST BE

CHOSEN FOR FOLLOW UP CARE

_____ I will select a doctor, if needed, from the approved panel.

_____ I decline to select a doctor from the above panel. I understand that I will have to pay for any

medical treatment or doctor’s bills, and that I will be denied workers’ compensation for any

absence based on a disability which is not certified by an approved panel doctor.

____________________________________________

________________

Signature of Employee

Date

____________________________________________

________________

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SUPERVISOR'S INVESTIGATION REPORT

Employee’s Name Department Job Title How Long on Job

Date of Injury/Illness Time Location Body part injured

What happened?

Root Cause Analysis - Check ALL that apply to this accident

Unsafe Act(s) Unsafe Condition(s)

Improper work technique Poor Workstation design

Safety rule violation Unsafe Operation Method

Improper PPE or PPE not used Improper Maintenance Operating without authority Lack of direct supervision

Failure to warn or secure Insufficient Training Operating at improper speeds Lack of experience

By-passing safety devices Insufficient knowledge of job Protective equipment not in use Slippery conditions

Improper loading or placement Excessive noise

Improper lifting Inadequate guarding of hazards Servicing machinery in motion Defective tools/equipment

Horseplay Poor housekeeping

Drug or alcohol use Insufficient lighting

What are the contributing factors to the root cause of the accident?

What should be done to prevent a future similar injury/illness?

Who will initiate the above corrective action?

Do you agree with the employee’s statements on the Official Occupational Injury/Illness Report? Yes/No (circle one) Comments:

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FAUQUIER COUNTY

WORKERS’ COMPENSATION

AUTHORIZATION FORM

This is a Workers’ Compensation Treatment Authorization Form. This Form is not a guarantee of

eligibility or compensability for Workers’ Compensation Benefits.

Please give this completed form to the injured employee to take with them to the

physician.

This form authorizes the health care provider treating me to give Fauquier County Human

Resources, or their Workers’ Compensation insurer, all information regarding my condition

(either orally or in writing), while under observation or treatment. This information may include

history, findings, x-ray readings, diagnosis, and prognosis as to subsequent or future

development; and to photocopy such records as may be requested.

In addition, I understand that approval of my Workers’ Compensation Claim is PENDING,

meaning that at this point it has neither been approved nor denied. Lastly, by signing this

form, I confirm that I have been presented with the County’s approved Panel Of

Physician’s form, and selected a physician accordingly.

___________________________________________________ ________________

Signature of Employee

Date

___________________________________________________ ________________

Signature of Employer/Supervisor

Date

All workers’ compensation questions, including pre-authorization, or questions regarding billing,

should be referred to Risk Management of Fauquier County Government & Public School Division,

Human Resources Department at 540-422-8300.

Send Medical Bills:

Fauquier County Human Resources

ATTN: Workers’ Compensation

320 Hospital Drive, Suite 34

Warrenton, VA 20186

SUPERVISORS:

EMPLOYEE AUTHORIZATION:

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PHYSICAL CAPABILITIES FORM

Name: ______________________________________Injury Date: __________________Age:_________ Employer____________________________________ Department/School_________________________ Injury/Complaint(s)_____________________________________________________________________ Diagnosis_____________________________________________________________________________ _____________________________________________________________________________________ Is complaint(s)/Diagnosis work related? Yes No

________________________________________________________________________

In an eight hour day, the patient can (please circle full capacity for each activity and check appropriate box)

With Restrictions Continuously Comments___________________ ___________________________ ___________________________ ___________________________ Stand 1 2 3 4 5 6 7 8 Hrs. Walk 1 2 3 4 5 6 7 8 Hrs. Sit 1 2 3 4 5 6 7 8 Hrs. ________________________________________________________________________________________________ In an eight-hour day, the patient can:

Lift up to Never Occasionally 0-33% Frequently 34%-66% Continuously 67%-100% 10 Lbs. 20 50 100 Carry up to: 10 Lbs. 20 50 100 Bend Squat Crawl Climb

Reach above shoulder level

________________________________________________________________________________________________ Patient can use hands for repetitive actions such as:

Simple Grasping Pushing/Pulling Fine Manipulation

Yes No Yes No Yes No

________________________________________________________________________________________________ Patient can use feet for repetitive movements as in operating foot controls

Right foot Yes No Left foot Yes No Both Yes No

Patient is restricted by environmental factors (heat/cold, dust, dampness, heights, fumes, gas, etc.) No restrictions Limited restrictions (please specify below)

If position requires, Patient can fully and safely operate vehicle without accompaniment Yes No

Patient can return to work on this date: ___/___/___ and can assume: Full duty Modified duty If modified duty, patient can return to full duty on (estimate date): ___/___/___

Modified duty restrictions:__________________________________________________________________________________

Medication prescribed:_____________________________________________________________________________________

Does medication prevent patient from working on or around equipment, machinery, or driving? Yes No

If answer is “yes”, explain:__________________________________________________________________________________

Date of follow up appointment ___/___/___ If referred, physician’s name_____________________________________________ Will patient require any assertive devices or braces to return to work Yes (specify below) No

Describe assertive devices needed, and restrictions they may cause:__________________________________________________ ________________________________________________________________________________________________________ Other comments:__________________________________________________________________________________________ ________________________________________________________________________________________________________ Physician’s name(please print):___________________________________________Telephone Number:___________________ Physician’s signature:_______________________________________________________________________Date: ___/___/___

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How to Report Workers’ Compensation Injuries

Incident Reporting Procedures

Employee Work-Related Injuries

In life-threatening situations, immediately seek medical assistance, then complete these claim forms!

To ensure the safety and well-being of our employees, we request your help in reporting work-related

injuries and illnesses as soon as possible. This allows prompt medical attention as well as the

correction of any existing hazardous conditions.

How Are Injuries Reported?

Workers’ Compensation claims are administered and adjusted by a third party administrator.

Employees should report all work-related injuries/illnesses to their supervisor within 24 hours of

injury. The employee and supervisor are responsible for completing the required paperwork and

immediately faxing the report to the H.R. Office:

540-422-8318

.

Supervisors Responsibilities Checklist

Make sure the following forms are completed:

 Employee Injury Report Form – It is the supervisor’s responsibility for providing this form to the

employee within 24 hours of the injury. This worksheet specifies the information needed when

reporting the claim.

 Workers’ Compensation Panel of Physicians - If medical treatment is needed, select a physician

from the School Division approved list of designated physicians. In the event of an emergency

requiring immediate medical treatment employees should obtain treatment at the nearest medical

facility. Notify the physician selected that all reports and bills are to be sent to the attention of the

Human Resources Office. (Failure to secure treatment from one of the panel’s physicians could

result in denial of benefits.)

 Supervisor’s Incident Report – Obtain a detailed description of the accident, as well as a specific

place and time at which the injury occurred and obtain employee’s signature.

 Authorization Form – Please give this form to the injured employee to take with them to the

physician if they seek medical treatment.

 Fax the (1) Employee Injury Report, (2) Panel of Physicians paperwork, and (3) Supervisor

Injury Report to the HR Office immediately,

540-422-8318

.

Failure to report such activities may affect benefits from workers’ compensation.

If you have any questions, please feel free to contact, Renee McNemar, Benefits & Risk Manager,

(540) 422-8309 or the HR Office at (540) 422-8300.

References

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