Employee Injury and Illness Policy

EMPLOYEE INJURY AND ILLNESS POLICY

Employer Information

Policy Purpose and Scope

This policy establishes the employer's procedures for reporting, documenting, investigating, treating, and resolving work-related injuries and occupational illnesses. It applies to all employees, contractors performing work for the employer on site, and to work performed at employer-controlled locations. The employer will comply with applicable workers' compensation laws and maintain records of occupational injuries and illnesses required by law.

Definitions

"Work-related injury or illness" means an injury or illness that arises out of and in the course of employment. "First aid" means minor treatment that does not require professional medical billing or extended care beyond immediate attention. "Recordable incident" follows the definitions used for required recordkeeping and reporting to regulatory authorities.

Employee Information (Acknowledgment)

Position Information

Start Date:

Employment History (Most Recent Employers)

Education

References

Reference 1

Reference 2

Reference 3

Reporting Procedures

Employees must report any work-related injury, illness, or near-miss to their immediate supervisor or the Safety Contact as soon as practicable, and no later than 24 hours after the incident unless incapacitated. Timely reporting is required to ensure medical care, investigation, and prompt claim filing with the employer's workers' compensation carrier.

I acknowledge that I will report injuries or illnesses within 24 hours:

Medical Treatment and Workers' Compensation

The employer will provide access to medical treatment in accordance with workers' compensation requirements. Employees must seek initial care at the designated facility unless otherwise directed by the employer or in an emergency. The employer will not retaliate against employees for filing a legitimate workers' compensation claim.

Return-to-Work and Light Duty

The employer will make reasonable efforts to provide temporary modified or light-duty work consistent with the treating clinician's restrictions and business necessity. Final determination of duties will be made by management in coordination with human resources.

I agree to cooperate with return-to-work evaluations and restrictions:

Recordkeeping, Privacy, and Release of Information

Medical information obtained in connection with an injury or illness will be maintained confidentially and disclosed only as necessary for workers' compensation administration, return-to-work placement, or required legal reporting. The employer will maintain records of occupational injuries and illnesses as required by law.

I consent to limited disclosure of medical information for claim handling and return-to-work:

Non-Retaliation and Enforcement

The employer strictly prohibits retaliation against any employee who reports a workplace injury, files a workers' compensation claim, or cooperates with an investigation. Violations of this policy may result in disciplinary action up to and including termination.

Training and Employee Responsibilities

The employer will provide safety training relevant to job duties. Employees are expected to follow safe work practices, use required personal protective equipment, report hazards, and participate in incident investigations as requested.

I acknowledge my responsibility to follow this policy and attend required safety training:

Legal Disclosures

At-Will Employment: Nothing in this policy alters the at-will employment relationship unless a written agreement signed by an authorized representative of the employer expressly states otherwise. Equal Opportunity: The employer provides equal employment opportunity and will not discriminate on the basis of any protected characteristic.

I have read and understand the At-Will and Equal Opportunity statements:

Authorization to Contact and Background Checks

I authorize the employer to contact prior employers and references for purposes of verifying employment history relevant to safety or claim investigation. I further authorize release of information necessary for workers' compensation and other lawful personnel actions, consistent with applicable privacy laws.

I consent to contact of prior employers and to background checks as required for position responsibilities:

Acknowledgment and Certification

I certify that all information provided on this form is true and complete to the best of my knowledge. I understand my obligations under this Employee Injury and Illness Policy, and I acknowledge that failure to comply with reporting or safety requirements may subject me to disciplinary action consistent with employer policy and applicable law.

I certify, under penalty of perjury, that the foregoing is true and correct:

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