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3.930 RCH Safety & Accident Prevention Program Form D-25 (Rev. 7/02, 02/04, 05/04, 3/05, 09/09, 10/09, 04/10) RESEARCH CORPORATION OF THE UNIVERSITY OF HAWAII SUPERVISOR'S REPORT OF INDUSTRIAL INJURY
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How to fill out supervisors report of injury
Steps to fill out a supervisor's report of injury:
01
Start by providing the necessary information of the injured person, such as their full name, job title, and employee ID number. Include their contact details like phone number and email address.
02
Specify the date and time of the injury incident. Be as accurate as possible to ensure clarity.
03
Describe the location where the injury occurred. Include the department, floor, and any relevant details about the specific area or equipment involved.
04
Provide a detailed account of how the injury happened. Include the sequence of events leading up to the incident, any witnesses present, and any actions taken immediately after the injury occurred.
05
Document any physical injuries sustained by the individual. Describe the type of injury, the affected body part or parts, and any visible wounds or marks.
06
If the injured person required immediate medical attention, note the medical facility they were taken to and provide details of any treatment received.
07
Include any additional pertinent information about the injury, such as whether it was caused by a specific event or equipment malfunction.
08
Once you have completed the report, sign and date it. If there is a designated space for the injured person to acknowledge the report, ensure they provide their signature as well.
Who needs a supervisor's report of injury?
01
Employers: The supervisor's report of injury is crucial for employers to keep accurate records of workplace incidents and fulfill legal obligations. It helps them track trends, identify safety hazards, and implement necessary preventive measures.
02
Employee: The injured employee or worker needs the supervisor's report of injury to initiate the workers' compensation process. This report plays a significant role in determining their eligibility for compensation and receiving appropriate medical treatment.
03
Insurance and legal entities: Insurance companies and legal representatives may require access to the supervisor's report of injury to evaluate claims or investigate the circumstances surrounding the incident.
04
Occupational health and safety authorities: Regulatory bodies responsible for workplace safety may request the supervisor's report of injury during inspections or investigations to ensure compliance with health and safety regulations.
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What is supervisors report of injury?
The supervisors report of injury is a document that details the circumstances surrounding an employee's injury while on the job.
Who is required to file supervisors report of injury?
Supervisors or managers who were present when the injury occurred are typically responsible for filing the report.
How to fill out supervisors report of injury?
The supervisor should provide a detailed account of the incident, including the date, time, location, and nature of the injury.
What is the purpose of supervisors report of injury?
The purpose of the supervisors report is to document the injury for workers' compensation and insurance purposes.
What information must be reported on supervisors report of injury?
Information such as the employee's name, job title, date of birth, and contact information should be included, along with a description of the injury and any witnesses.
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