CANTON CITY SCHOOLS

INCIDENT REPORT

PART 1 – INJURED EMPLOYEE’S STATEMENT

I, _______________________________, certify that on _____________________,2000 at _________(AM or PM)

Sustained an injury to my (part of body, be specific) ___________________________________________________

Which occurred as follows: _______________________________________________________________________

Did injury occur on Company property? ______yes _____no On Company time? _____yes _____no

List names of any witnesses (if none, write NONE):____________________________________________________

To whom did you report the incident? _________________________ Date & Time Reported:________________

Was medical attention necessary? _____yes _____no If yes, please report injury to the benefits office immediately.

If yes, state name of hospital or facility and doctor you were seen by:______________________________________

Have you had any previous injuries? _____yes _____no If yes, list dates: ________________________________

What is your current job title? ___________________________ What school location? ________________________

How long have you been at present job? _____yrs. _____mos. Your age: _________ Male _____ Female ______

_____________________ _______________________________________

Date of this report Employee’s signature

Employee’s social security number Home telephone number

MEDICAL INFORMATION RELEASE (Signature Required)

As provided by section 4123.651 © of the Ohio Revised Code, I hereby permit the release of medical information,

Records and reports relative to the issues necessary for the administration of my Workers’ Compensation claim to my employer representative(s). A photocopy of this authorization shall serve as an original.

_______________________ ______________________________________

Date Employee’s signature

Once this form is completed, keep a copy for your records, then give the original to your supervisor for completion and distribution.

PART II – WITNESS STATEMENT TO INCIDENT

Witness Name (if more than one, use separate sheet)____________________________

Please describe the incident (how, when and where), in detail, that you saw:_________________________________

What is your current job title? __________________________________________

What school location do you work at? ____________________________________

PART III – SUPERVISOR’S INVESTIGATION OF INCIDENT

Injured employee’s name_________________________ School location___________________________________

Date & time he/she reported the incident to you___________________________(AM or PM)

Part(s) of body reported as injured_______________________________________________________

State the events (as reported to you by the employee) how the incident happened:_____________________________

__________________________________________________________________________________

Was this on Company property? _____yes _____no On Company time? _____yes _____no

Was investigation necessary? ____yes ____no If yes, describe the incident investigation procedure and results:

Was the accident preventable? _____yes _____no If yes, describe: ________________________________________

What corrective action was taken to prevent this from happening again? (if none necessary, state as such)__________

Did employee miss any work? _____yes _____no If yes, please state dates:_________________________________

State employee’s regular weekly work schedule: _______________________________________________________

Date you received this from employee Date you sent completed form to benefits Date benefits received completed form

_________________________________ ______________ _______________________________________

Supervisor’s Signature Date School or Location

Please send completed original to the Benefits Office – Wells Building.

Please keep a copy for your file.