Fill and Sign the Bir 1902 Form 2008 2019

IWIF English/Español Accident Investigation FORMS How To Use These Important Tools Includes: Employee's Report of Injury Form Accident Witness Statement Form Supervisor's Accident Investigation Form Forms may be copied as needed. ✍ Accident investigation forms/statements should be filled out by the injured employee, supervisor or any witness to the accident. Train your supervisors to conduct the preliminary investigation as soon as possible. IMPORTANT - Care must be taken to assure the investigation is fact finding, not fault finding. Obtaining signed statements as soon as possible following an accident insures that you, the employer, have an accurate account of how the injury occurred. These completed statements are important in helping to correct hazards and prevent the accident from recurring. They also help to spot possible third-party liability as well as possible fraudulent claims. After I have these forms completed - what do I do with them? Hold on to them. When you call the COMPcall injury hotline to report the accident, advise the operator that these forms were completed or if you are planning to have the forms completed. Please keep the completed forms for future reference and inform the IWIF claims adjuster you have them if needed. These completed forms can be valuable information in the claims investigation of an injury and for building a case in the event of a workers comp hearing. What if my injured employee is physically unable to fill out the Employee’ Report of Injury? s Use common sense and good judgement. If the injury is severe - remember, your employee’s health and care are first and foremost. If possible, have the form filled out at a later, more appropriate time when the employee is physically able to document the accident. What if my employee refuses to fill out or sign an Employee’ s Report of Injury? Of course, you cannot make an employee fill out the document. You can however stress the importance of getting “their” account of the accident to help prevent the injury from happening again. Also, still obtain the supervisor's report as well as any witness statements. Need Help? If you would like assistance in setting up supervisory training on how to use these forms, please contact your IWIF loss control consultant or call 410-494-2071. 204 3/01 15m What if my Employee has retained an attorney - Can I still ask the injured employee to fill out an Employee's Report of Injury? Yes - you, the employer as part of your company's accident management plan, can still ask the employee to fill out the report form. IWIF • 8722 Loch Raven Boulevard, Towson, MD 21286-2235 • www.iwif.com IWIF Employee's Report of Injury (To be completed by the employee) Employee's name: __________________________________________________________ Male__ Female__ Last Date of birth: ____/____/____ First Middle Home Telephone # ( ______ ) _________________________________ Home Address: ___________________________________________________________________________ City: ______________________________________________ State: ______ Zip Code: _________________ Present classification: __________________________________ How long employed here: _____________ Social Security No.: _______-______-__________ Bi-weekly salary: ______________________________ Location of accident: ______________________________________________________________________ Name of building Area (bathroom, etc.) Date of accident: _________________________________________ Time of accident: __________________ Describe fully how accident occurred: ________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ (continue on other side, if necessary) Describe bodily injury sustained (be specific about body part(s) affected): ___________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ Recommendation on how to prevent this accident from recurring:____________________________________ _______________________________________________________________________________________ (continue on other side, if necessary) Name of Supervisor: ______________________________________________________________________ Last First Middle Name(s) of Witness(es): ___________________________________________________________________ (Attach witness(es) report(s)) When did you report the accident to your supervisor? ____________________________________________ Signature of employee: ________________________________________ Date: ______________________ 3/01 IWIF • 8722 Loch Raven Boulevard, Towson, MD 21286-2235 • www.iwif.com Form may be copied as needed IWIF Accident Witness Statement (To be completed by accident witness) Injured Employee's name: _____________________________________________ Last First Middle Name of Witness: ___________________________________________________ Last First Middle Job title of Witness: _________________________________________ How long employed here?________ Home address of witness: __________________________________________________________________ City: ______________________________________________ State: ______ Zip Code: _________________ Location of accident: ______________________________________________________________________ Address/Name of building Area (bathroom, etc.) Date of accident: _________________________________________ Time of accident: __________________ Describe fully how accident occurred: ________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ (continue on other side, if necessary) Describe bodily injury sustained (be specific about body part(s) affected): ___________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ Recommendation on how to prevent this accident from recurring:____________________________________ _______________________________________________________________________________________ (continue on other side, if necessary) Name of Supervisor: ______________________________________________________________________ Last First Middle Signature of Witness: ________________________________________ Date: ______________________ 3/01 IWIF • 8722 Loch Raven Boulevard, Towson, MD 21286-2235 • www.iwif.com Form may be copied as needed IWIF Supervisor's Accident Investigation (To be completed by the employee's supervisor or other responsible administrative official) Location where accident occurred Who was injured? Length of time with firm Job title or occupation What property was damaged? Employer's Premises: Yes No Date of accident or illness Job site: Yes No Employee Time of accident a.m. Non-Employee p.m. Name of dept. normally assigned to How long has employee worked at job where injury or illness occurred? Property owned by What was employee doing when injury/illness occurred? What machine or tool? What operation? How did injury/illness occur? List all objects and substances involved. Part of body affected Any prior physical defects? If so, what? Yes No Nature and extent of injury/illness and property damaged (be specific) PLEASE INDICATE ALL OF THE FOLLOWING WHICH CONTRIBUTED TO THE INJURY OR ILLNESS ____ Improper instruction ____ Failure to lockout ____ Unsafe arrangement or process ____ Lack of training or skill ____ Unsafe position ____ Poor ventilation ____ Operating without authority ____ Improper dress ____ Improper guarding ____ Horseplay ____ Improper protective equipment ____ Improper maintenance ____ Physical or mental impairment ____ Unsafe equipment ____ Inoperative safety device ____ Failure to secure ____ Poor housekeeping ____ Other ____________________ Supervisor's corrective action to insure this type of accident does not reoccur: ______________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ ______________________________________________________________________________________________________ Was employee retrained in the appropriate use of Personal Protective Equipment/Proper safety procedures? Yes ___ No ____ Was employee cautioned for failure to use Personal Protective Equipment/Proper safety procedures? Supervisor's name 3/01 Yes ___ No ____ Supervisor's signature IWIF • 8722 Loch Raven Boulevard, Towson, MD 21286-2235 • www.iwif.com Form may be copied as needed Date