PCI CA Supervisor Injury Statement

WORKERS’ COMPENSATION INJURY SUPERVISOR’S STATEMENT
PCI Location*
SLIP, TRIP, FALLCAUGHT BETWEENSTRUCK BYMVA RELATEDOTHER
Employee Name

First NameLast Name
Employee Job Title*
Employee Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Employee Email Address
example@example.com
Is the employee Permanent/Temporary/Part-Time:
Days Employee Works
Hours Employee Works
Are there any questions or concerns about the injury? Red flags?
Performance issues/Good worker?
Were there any witnesses?
Name(s) of Witnesses
Witness Job Title and email address/phone number
Last Day Worked?

MonthDayYear
Date
Has the employee returned to work?
Regular or Modified Duty?
Is modified duty available?
Work restrictions?
SS#
Date of Hire

MonthDayYear
Date
Supervisor*
Location Where Injury Occurred
Date of injury

MonthDayYear
Date
Time of Injury
Date Reported to You

MonthDayYear
Date
Time Reported to You
Task being performed when incident/injury occurred (Please be specific – identify tools, equipment or material the Employee was using or working on)
InjuryFatalityProperty Damage/Loss
First aid given
Medical treatment required
Workdays lost
STEP 1. Describe How Accident Occurred
STEP 2. What body parts did the employee say were injured? (List all)
STEP 3. What actions, events or conditions most directly contributed to this accident?
STEP 4. What actions have or will be taken to prevent recurrence?
Was medical treatment requested?
Defective Equipment?
3rd party involved (Subrogation)?
Was there a police report? (If applicable)
Prior WC or non-WC injuries that you are aware of?
List:
Outside activities/Hobbies that you are aware of?
PreventableNon-preventable
Supervisor Signature*
Supervisor Phone
Format: (000) 000-0000.
SUPERVISOR EMAIL
example@example.com
Date

MonthDayYear
Date
Should be Empty:

WORKERS’ COMPENSATION INJURY SUPERVISOR’S STATEMENT