Event Date(Required) MM slash DD slash YYYY Injured Staff InformationEmployee Name(Required) First Last Employment Status(Required)Full-TimePart-TimePRNCurrent position(Required) Social Security Number(Required) Phone(Required)Date of Birth(Required) Month Day Year Marital Status(Required) Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Occurrence & InjuryHas the staff EVER had any previous injuries to these body parts?(Required) Yes No If yes, Please provide the month and year of last injury plus the name(s) of prior doctor(s)(Required) Date of Injury(Required) MM slash DD slash YYYY Shift Start Time(Required) Hours : Minutes AM PM AM/PM Shift End Time(Required) Hours : Minutes AM PM AM/PM Time of Occurrence(Required) Hours : Minutes AM PM AM/PM Date Employer Notified(Required) MM slash DD slash YYYY Were safeguards provided?(Required) Yes No Were they used?(Required) Yes No Were there any witnesses?(Required) Yes No If Yes, provide name and contact info (i.e., email and phone number)What consumer were they working with?(Required) Location(Required) Please give a precise and detailed account of how the accident occurred(Required)List all body parts that are allegedly injured(Required) Type of injury(Required) What happened immediately BEFORE the accident?(Required)What happened immediately AFTER the accident?(Required)Were ALL First Aid Strategy’s exhausted prior to going to an Urgent or Take Care Clinic)(Required) Yes No If no, why not? What steps were taken?(Required) Has staff ever been previously injured while working with any consumer in our agency?(Required) Yes No If yes, where and when? In what way(s) could this injury have been prevented?(Required) Were all proper steps of the Behavior Support Plan (BSP) followed?(Required) Yes No If no, why not? Were any health and safety rules violated?(Required) Yes No If yes, which ones? Did the accident occur while the claimant was simply walking or up/down stairs?(Required) Yes No Does injured staff need a tetanus shot?(Required)(If yes, BIS will pay for the claimant to get a shot from their primary physician or at a Take Care Clinic) Yes No Could anything have been done to prevent this accident?(Required) Yes No If yes, what? Any why was it not done? What was the employee/claimant doing before the injury?(Required) What was the consumer doing before the injury?(Required) Is this a reoccurring injury?(Required) Yes No Does employee/claimant need to go to an Urgent Care facility?(Required) Yes No Is claimant aware that a Drug & Alcohol test is required within 24 hours from the time the accident occurred?(Required) Yes No Has the claimant been informed of the approved locations of Urgent Care Facilities?(Required) Yes No Which facility have you contacted?(Required) Has the claimant signed the Approval to Release Information form?(Required) Yes No Claimant Signature(Required)Date(Required) MM slash DD slash YYYY
