Fill and Sign the Lsu Official Transcript Request Form PDF

Screen reader users can use arrow key and header navigation to review the text content of this form. Use the tab key to enter into the form to begin filling it out. Employee Accident Report READ THESE INSTRUCTIONS BEFORE PROCEEDING The Employee Accident Report must be completed for every work-related accident or illness. (Medical complex personnel refer to Employee Health Web Page on the intranet.) This report will: 1. Assist employees in obtaining immediate medical treatment 2. Inform supervisor/charge person of accident 3. Be recorded for follow-up and future prevention Below are guidelines for completing this form (please print neatly in ink or complete electronically) Employee Responsibilities: 1. Immediately notify supervisor/designated charge person of work-related accident or illness. 2. Fully complete “Employee Information” and “Accident Information” sections, sign and date the report. 3. Give form to supervisor/charge person for signature. 4. Seek medical treatment if necessary (see “Medical Treatment” section below). Supervisor/Charge Person Responsibilities: 1. Complete “Supervisor/Charge Person” section, sign and date the report. If the employee needs or desires medical treatment, assist in the arrangement of appropriate care (see “Medical Treatment” section below). 2. Make a copy of this report for your records and provide the original to the employee. 3. Immediately submit a copy of this completed accident report to Integrated Disability by either fax or e-mail as indicated on page two. MEDICAL TREATMENT Send employees for treatment with this form within 72 hours after the accident is reported. Columbus campus employees should seek treatment for work-related injuries and/or illness at: OSU University Health Services McCampbell Hall, 2nd floor 1581 Dodd Drive Phone: 614-293-8146 Fax: 614-293-8018 Hours: M–F, 7:30 a.m. to 4 p.m. (There is no cost for medical treatment of employee accidents or injuries at University Health Services.) If Employee Health Services is closed or unavailable, seek treatment at: OSU Occupational Medicine – CarePoint East 543 Taylor Ave., 2nd floor Columbus, OH 43203 OSU Occupational Medicine – CarePoint West 86 N. Wilson Road Columbus, OH 43204 Phone: 614-688-6492 Phone: 614-293-3500 Hours: M–F, 8 a.m.–5 p.m. Hours: M–F, 8 a.m.–5 p.m. After Hours Care Martha Morehouse Medical Plaza 2nd Floor, Suite 2400, Pavilion 2050 Kenny Road Columbus, OH 43212 Phone: 614-685-3357 Hours: M–F, 5 p.m.–11 p.m. SAT–SUN, 10 a.m.–6 p.m. After normal business hours or on weekends, for non-emergencies, seek treatment at University Health Services during normal business hours. After normal business hours, seek treatment at After Hours Care. If life threatening, seek emergency treatment at Ohio State’s Wexner Medical Center Emergency Department or University Hospital East Emergency Department. (Hospital employees should report to University Health Services the next day.) Regional campus employees should seek treatment at the designated local health provider. For blood and body fluid exposures (BBFE): Employees must report blood and body fluid exposures immediately to their supervisor and complete the BBFE Addendum to this report. Wexner Medical Center personnel should refer to Blood and Body Fluid Exposure Protocol for instructions. All others should call Employee Health Services at 614-293-8146 for instructions. WORKERS’ COMPENSATION RIGHTS Employees have the right to apply for Workers’ Compensation benefits. They have two years from the date of this accident to do so. For more information regarding Workers’ Compensation, call 614-292-3439. Submit this report to Integrated Disability: Fax: 614-688-8120; Email: accidentreport@osu.edu Office of Human Resources, EAR001, rev. 5/14 Employee Accident Report, Page 1 of 3 SECTION 1: EMPLOYEE INFORMATION (all fields required) ______________________________________________________________________________________________ Employee’s Full Name: First M.I. Last Full Time City Home Mailing Address: Street OSU Employee ID# State Part Time Zip Home Phone Date of Birth Sex Age Job Title Department Work Phone Date Hired Zip Work Address: Street City State Supervisor’s Full Name: First Last Supervisor’s Phone SECTION 2: ACCIDENT INFORMATION (provide as much detail as possible) Accident date: Accident time: Date of death, if applicable: Location of accident (room#/building/shop): A.M. P.M. Time shift began: A.M. P.M. Briefly explain the accident and what was being done just prior: Yes Was this part of your normal job duty? Body part(s) affected/injured (circle on diagram) No What object or substance directly harmed the employee? L ___________________________________________________________________ Type of injury or illness: ________________________________________________ R Eyes/Ears/Face Neck/Shoulders/Arms/Elbows Hips/Legs/Knees Witness (name and phone): _____________________________________________ Did employee seek medical treatment? Wrist/Hands/Fingers No Yes Ankles/Feet/Toes If yes, where? _______________________________________________________ Back (Upper/Lower) This report prepared by (name and phone, if different from injured employee): Head Internal Organs Other: For blood/body fluid exposure, the Addendum (on page 4) must be fully completed. R L L Front Hospital Medical Record# of source patient: R Back Please review the Medical Treatment information on page 1 of this form. If no medical treatment is necessary or if treatment is sought somewhere other than University Health Services (UHS), submit a copy of this completed report to Integrated Disability at Fax: 614-688-8120 or email: accidentreport@osu.edu. SECTION 3: EMPLOYEE AUTHORIZATION I understand that it is my right to apply for Workers’ Compensation benefits and that I have two years from the date of this accident to do so. I also authorize release of medical information regarding this accident to OSU BWC claim administrators. _________________________________________________________ ___________________________________________________________ Employee Signature Date SECTION 4: TO BE COMPLETED BY SUPERVISOR/CHARGE PERSON This accident was reported to me on: Date: Is further investigation required? Time: Yes No Cost Center/Department#: If yes, why: _________________________________________________________ ___________________________________________________________ Signature of Supervisor/Charge Person Date SECTION 5: TO BE COMPLETED BY HEALTH CARE PROVIDER Treated by University Health Services? Yes No If no, treated by? Medical provider printed name: Medical provider signature: Diagnosis/Assessment: Body part(s) affected: Date treated: Reaggravation of a previous injury? Full Duty Yes Restricted Duty No If yes, date of initial injury: Date (if restricted, please use MEDCO-14): OSHA/PERRP 300 Classification Injury/Illness: (Check only 1 box) Severity: (check only 1 box): (1) Injury - All Other Not Recordable (2) Skin Disorder (3) Respiratory Condition (J) Other Recordable Cases (4) Poisoning (I) Restrictions or Job Transfer (5) Hearing Loss (6) Illness - All Other (H) Days Away from Work (G) Death Medical Record# ATTENTION: This form contains information relating to employee’s work-related injury and must be used in a manner that protects the confidentiality of the employee to the maximum extent possible. The Genetic Information Nondiscrimination Act of 2008 (GINA) prohibits employers and other entities covered by GINA Title II from requesting or requiring genetic information of an individual or family member of the individual, except as specifically allowed by this law. To comply with this law, we are asking that you not provide any genetic information when responding to this request for medical information. ‘Genetic information,’ as defined by GINA, includes an individual’s family medical history, the results of an individual’s or family member’s genetic tests, the fact that an individual or an individual’s family member sought or received genetic services, and genetic information of a fetus carried by an individual or an individual’s family member or an embryo lawfully held by an individual or family member receiving assistive reproductive services. Submit copies to: (1) Integrated Disability: Fax: 614-688-8120 or email: accidentreport@osu.edu Office of Human Resources, EAR001, rev. 5/14 (2) Supervisor/Department (3) Injured Employee Employee Accident Report, Page 2 of 3 Blood/Body Fluid Exposure Addendum ALL parts of this form MUST be completed with as much detail as possible. This form must be submitted directly to Integrated Disability (not to supervisor). SECTION 1: EMPLOYEE INFORMATION Employee’s Full Name: First M.I. Occupation Phone Number (for reporting lab results) Date of exposure: Last OSU Employee ID# Time of exposure: Date of Hire Number of hours on duty: Pregnant: Yes No SECTION 2: BBFE INFORMATION Specific location of exposure (room# and building): _________________________________________________________________________________________________ Location type (patient room, laboratory, bathroom): ________________________________________________________________________________________________ Cause of the exposure (splash, needlestick, bite): __________________________________________________________________________________________________ Detailed account of the event (be as specific and detailed as possible): _________________________________________________________________________________ __________________________________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________________________________ In your opinion, what could have prevented this BBFE? (be specific): ___________________________________________________________________________________ SECTION 3: NEEDLESTICKS/SHARPS INJURIES Was the sharp item: Contaminated Uncontaminated Unknown Source of contamination (blood; other–please specify): ___________________________________________________________________________________________ Depth of injury: Superficial (surface scratch) Was the sharp being held? Yes If not, was the sharp: Hands too close to someone else handling sharp Dropped by someone else Set aside for future use Being passed by someone else Inappropriately discarded or left there by someone else Type of sharp: Needle for blood draw Push button butterfly Multi sampling needle Slide safety butterfly ABG needle Syringe to draw cord blood Other Peripheral IV Angioset (butterfly) Angiocath (straight) Needle for injection Central line placement Lidocaine Introducer Scalpel Other Insulin pen Novo Nordisk Innolet (Reg or NPH) Novo Nordisk Flex Pen (Novolog Aspart or 70/30) Solostar (Lantus) Lilly (Humalog) Huber needle Safety Non-safety EMG/SSEP needle Suture needle Being reused Set aside for reuse Stuck self while administering If administering lidocaine, was needle: Moderate (penetrated skin) Deep puncture or wound No Surgical instrument ____________________________ Recapping If scalpel, was it a safety (retractable) scalpel? ___________________________________________________________________________________________________ Do you feel the device was defective?* ________________________________________________________________________________________________________ *If YES, please save device for University Health Services if possible. SECTION 4: SPLASHES Was this exposure related to a splash? _________________________________________________________________________________________________________ Fluid Involved: Blood Vomitus Vent condensation Urine Stool Sweat, tears Saliva, sputum CSF, synovial, pleural, peritoneal, pericardial, or amniotic fluid If urine, sweat, vomitus, stool, saliva, sputum, or vent condensation, was fluid visibly bloody? ______________________________________________________________ What type of personal protective equipment (PPE) was worn during exposure? _________________________________________________________________________ Gloves Gown If splashed, fluid came in contact with: Glasses Goggles Mask with face shield Intact skin Nose Non-intact skin Mouth Mask Eyes Other Did someone else inadvertently splash you? ____________________________________________________________________________________________________ If this BBFE was caused by a splash, list barrier protections that could have prevented it: _________________________________________________________________ Office of Human Resources, EAR001, rev. 5/14 Employee Accident Report, Page 3 of 3