WHAT SHOULD I DO IF I HAVE A WORK-RELATED INJURY?
1) In a serious emergency, call 911 or go to the nearest hospital/trauma center! Follow-up care is to be arranged with one
of the district’s designated medical providers listed below. If the injury is not a serious emergency but occurs after hours and you need to be seen by a physician, you are authorized to go to the nearest urgent care facility. Follow-up care is to be arranged with one of the district’s designated medical providers listed below.
2) If the injury is not a serious emergency, you must contact Human Resources (Beth Collins at 720-561-5936 or
[email protected]) to make arrangements to see one of the district’s designated medical providers listed below. You
are not authorized to see your personal physician and have Workers’ Compensation pay the claim. Human
Resources will assist you with your appointment. The Employee Report of Injury/Incident (available on the BVSD website at http://bvsd.org/benefits/Pages/workerscompensation.aspx and in Human Resources) must be filed through Human Resources in order for your bills to be eligible to be paid under Workers’ Compensation.
3) Notify your supervisor.
4) You will be seen by the district’s designated medical providers. You must select a designated provider from the list in the
table:
Arbor Occupational Medicine
One Walden Building 4790 Table Mesa Drive Suite 200
Boulder, CO
303.443.0496
M-F 8:00 AM – 5:00 PM
Arbor Occupational Medicine
290 Nickel Street Suite 200
Broomfield, CO
303.460.9339
M-F 8:00 AM – 5:00 PM
Boulder Community Hospital Occupational Health and Therapy Services 4745 Arapahoe Avenue Suite G40 Boulder, CO 80303 720.854.7854 M-F 8:00 AM – 4:30 PM
By Appointment By Appointment By Appointment
5) It is your responsibility to inform Human Resources (Beth Collins) and your supervisor of your progress and any time off
work. Workers’ Compensation will not pay for time off work that is not authorized by the district’s designated medical provider. If you cannot return to your regular duties, alternative duties may be temporarily assigned.
Questions? Call Human Resources (Beth Collins) at 720-561-5936. We’ll help you through your injury and back to work!
If you experience a minor injury or an incident whereby you don’t need medical treatment, you still need to report it. Please follow the process listed below.
1) Notify your supervisor.
2) Call Human Resources (Beth Collins) at 720-561-5936 and complete Employee Report of Injury/Incident (form #2) of the
packet titled, Workers’ Compensation Information and Forms, available through Human Resources or on the BVSD website http://bvsd.org/benefits/Pages/workerscompensation.aspx and return to Beth Collins in Human Resources.
Workers’ Compensation Form #1 08//01/09
E
MPLOYEE
R
EPORT OF
I
NJURY
/I
NCIDENT
(TO BE COMPLETED BY EMPLOYEE)
DATE OF REPORT:
DATE OF INJURY/INCIDENT:
NAME OF EMPLOYEE:
WORK SITE (WHERE INJURY/INCIDENT OCCURRED): WORK PHONE:
I certify that the following statement is a true and accurate account of the events that happened:
Employee Signature:
Was there a witness(es) to the injury/incident? Yes No If yes, please provide name(s) of witness(es):
I received the Designated Provider information, Workers’ Compensation Form #3 included in this packet.
Employee Signature:
Boulder Valley School District
D
ESIGNATED
P
ROVIDER
L
IST
In a serious emergency, call 911 or go to the nearest hospital/trauma center! Follow-up care is to be arranged with one of the district’s designated medical providers listed below.
If the injury is not a serious emergency, you must contact Human Resources (Beth Collins at 720-561-5936 or [email protected]) to make arrangements to see one of the district’s designated medical providers listed below.
You are not authorized to see your personal physician and have Workers’ Compensation pay the claim.
Human Resources will assist you with your appointment.
Arbor Occupational Medicine
One Walden Building 4790 Table Mesa Drive Suite 200
Boulder, CO
303.443.0496
M-F 8:00 AM – 5:00 PM
Arbor Occupational Medicine
290 Nickel Street Suite 200
Broomfield, CO
303.460.9339
M-F 8:00 AM – 5:00 PM
Boulder Community Hospital Occupational Health and Therapy Services 4745 Arapahoe Avenue Suite G40 Boulder, CO 80303 720.854.7854 M-F 8:00 AM – 4:30 PM
BVSD’s claims administrator responsible for Workers’ Compensation is CCMSI. The following are designated as BVSD and administrator representatives:
• Beth Collins, Workers’ Compensation Specialist Human Resources
Boulder Valley School District PO Box 9011 6500 Arapahoe Boulder CO 80301
Phone: 720.561.5936, Fax: 720.561.5217
• Paula Lowder, Claims Adjuster CCMSI
PO Box 4998
Greenwood Village CO 80155
Phone: 303.804.2024, Fax: 303.804.2005
The EMPLOYEE REPORT OF INJURY/INCIDENT must be filed through Human Resources in order for your bills to be
eligible to be paid under Workers’ Compensation.
This list was provided to by
on , by
month date year
Hand-delivery U.S. mail E-mail Facsimile Other ___________________________ Signature of Employer Representative Date
Boulder Valley Schools
Supervisor’s Accident/Incident Investigation Report
To be completed by the Supervisor
See Next Page for Instructions
I.
Ge
neral Infor
m
ation
School/Department: Name of Person Completing Form: Employee Name: Job Title:
Employee Number: Sex: M F
Date of Accident/Incident: Time of Accident/Incident: AM PM Type of Accident/Illness/Incident: Name(s) of Witness(es):
Type of Injury/Incident: Part of Body Injured:
Treatment:
First Aid Medical Where?
Did Employee Return to Work the Same Day? Yes No
II.
Des
crip
tion
Where and how did accident/incident happen? (Please provide brief description.)
III.
Cause
s
Specific employee act, (action, task or activity) connected with the accident/incident:
Unsafe condition at time of accident/incident (please be specific):
Unsafe personal factors at time of Accident/Incident:
Personal Protective Equipment (PPE) required, i.e. eye, hand, foot protection, etc.:
Was employee using required PPE? Yes No
IV
. Recommen
d
ation
s
Action plan to prevent recurrence (modification of machine, mechanical guarding, environment, training):
Supervisor's name (please print)
Supervisor’s signature Date
V.
F
o
llow-up
Actions taken on recommendations (include date completed, if possible):
Send Form to Human Resources ASAP, and File One Copy at Your Department/School for Safety Use and Review
Instructions For Completing Accident/Incident Report (on reverse side)
Please print or type all information. Complete report in as much detail as possible.
I. General Information
Fill in all information requested: Name of person injured, date, exact location, job title, job being performed, etc. For description of type of accident/illness/incident, injury, and body part, see the following:
A. Type of Accident/Illness/Incident • slip/fall • struck by/against • caught in/on/between • contact with/by/hot object/electric current • overexertion/lifting/carry/hold/ push/pull • cut by • amputation • inhalation
• injured by hand tool not powered/or by power tool
B. Type of Injury • cut • bruise • puncture • abrasion • strain • sprain • burn • irritation • swelling • fracture
C. Part of Body Injured (select as many as needed)
• thumb/finger/hand/wrist • elbow/arm/shoulder • toe/foot/ankle • leg/knee/hip • head/neck/face • nose/eye/ear/throat • chest/abdomen
• upper back/lower back
• respiratory
II. Description of Accident/Incident
Describe in as much detail as possible where and how the Accident/Incident happened. This section is for facts, not opinion. Statements the injured or witnesses made should be detailed. Use an additional piece of paper if more space is needed. Include sketches or photos if they help explain what happened.
III. Accident/Incident Causes (see casual factors below)
Unsafe Acts, Conditions, and/or Personal Factors involved.
IV. Recommendations
Once causes are identified, action must be taken to prevent the same thing from happening again. Realistic, yet effective, recommendations should be implemented. The form should be signed and dated by the appropriate supervisor.
VI. Follow-up
List actions that have been taken and their respective completion date. Proper follow-up should continue on any incomplete recommendations.
Accident/Incident Causal Factor(s)
A) Unsafe Act
1. Working or operating without authority
2. Working at unsafe speeds 3. Making safety devices
inoperative
4. Taking unsafe position or posture 5. Unsafe manual materials
handling
6. Using defective tools 7. Using hands instead of tools 8. Unsafe loading or unloading 9. Failure to use personal protective
equipment (Be Specific) 10. Distracting, teasing or horseplay 11. Not following rules or
instructions
12. Other (Give complete details) 13. No unsafe act
B) Unsafe Condition
1. Improperly guarded 2. Safety devices inoperative 3. Defective
4. Hazardous arrangement (incl. poor housekeeping)
5. Improper illumination 6. Improper ventilation 7. Lack of suitable personal
protective equipment 8. Unsafe dress or apparel 9. Hazardous dust, gases or fumes 10. Other (Give complete details) 11. Environmental (i.e., wet, icy,
slippery, hot, cold, etc.) 12. No unsafe condition
C) Unsafe Personal Factor
1. Improper attitude 2. Lack of required safety
knowledge or skill 3. Defective eyesight 4. Defective hearing 5. Fatigue
6. Muscular weakness 7. Pre-existing heart weakness 8. Pre-existing hernia
9. Intoxicated (under the influence of alcohol, drugs, etc.)
10. Other (Give complete details) 11. Slow reaction time
12. No unsafe personal factor
