Jobsite Injury Protocol Checklist
Employee name
Incident date
/
Month
/
Day
Year
Date
Check the following if completed
Call 911 if life threatening.
Call WorkPartners if non-life threatening
Report to onsite Safety Coordinator and Safety Manager.
Complete accident report
Complete California 5020 injury report. (Only if injury requires more than first aid.)
Provide employee with California workers compensation form DWC 1. (Only if employee has a workplace injury that requires treatment beyond first aid protocol.)
Additional Comments
Preview PDF
Submit
Should be Empty: