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)
*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
____________________________________________
________________
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:
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:
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: ___/___/___