irst Report of Injury / Incident

EMPLOYEE ACCIDENT

FIRST REPORT OF INJURY

Instruction: Complete this First Report of Injury form only when an employee sustains a work-related injury or occupational illness.
- Full Name*
  
  First NameMiddle InitialLast Name
- Mailing Address*
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Primary Personal Phone Number*
  Format: 000-000-0000.
- Email*
  example@example.com
- Date of Birth*
  
  MonthDayYear
- MaleFemaleN/A
- Date of Injury / Incident*
  
  MonthDayYear
- Time of Injury / Incident:*
  
  AM/PM Option
- Occupation / Position Title*
- Time Shift Begins:
  
  AM/PM Option
- Witness(es):
- Phone Number of Witness:
  Format: 000- 000-0000.
- Date Reported to Supervisor:*
  
  MonthDayYear
- Jason Stanoch / Mellissa Newstrand - High School / AECDrew Hildenbrand / Jennifer Sanford - Middle SchoolAmi Aalgaard / Amy Gano - Gene DillonChristine Christiansen / Laurie Dokken - Horace MayJason Luksik / Elaine Miller - LincolnBruce Goodwin / Gracelyn Anderson- JW SmithAmy Worden / Karin Revering - NorthernAmy Worden / Jill Wagner - SolwayRachel Amdahl / Eileen Campbell - Community Ed / Jack & JillTammie Colley - Food ServicesTricia Jessen - Kids & CoTiffany Palmer - LLC / First City / EICPaul Rafferty / Mike Jessen / Terri Jurkovski - Plant OperationsEmily Helm / Susan Flicek / Lori Yerbich - Related ServicesJeremy Jensen / Monica Gregerson - TransportationBill Owens- WarehouseDistrict Office
- Bemidji High SchoolBemidji Middle SchoolDistrict WarehouseDowntown Education Center / LLCFirst CityGene DillonHorace MayJack & JillJW SmithLincolnMaintenanceNorthernPaul BunyanSolwayTransportationOther
- Specific Location in the Building (example: hallway, classroom, door number etc.)*
- YesNo
- YesNo
- YesNo
- Describe the incident in detail? Include what happened, how it happened, and the events leading up to the injury. *
- Body Part(s) Affected (e.g., left wrist, right ankle, lower back), including orientation (right, left, upper, lower). If applicable, specify any illness you are experiencing.*
- Type of Injury (e.g., laceration, sprain, contusion, fracture, burn)? Details/Relevant Information (e.g., size/severity, cause of injury, immediate treatment provided) Are you planning to seek medical attention for this injury? ( etc.).*
- If medical treatment is required Employees are required to bring a Report of Workability form to each medical appointment. The attending provider must complete this form following every visit, and it must be returned to the Business Services office. Employees are responsible for ensuring that all completed forms are submitted in a timely manner. The physician must fax a Report of Workability to 218-395-6325.
- YesNo
- Contact the District Nurse at 218‑333‑3115, ext. 37209 or the Safety Manager at 218‑333‑3149 immediately. If deemed necessary, blood work must be completed within 12 hours of exposure.
- SECTION 4a - Exposure Details
- EyesNoseMouthOther Mucous MembraneNon-Intact SkinNeedle stick, Puncture, Bite or ScratchOther
- BloodSalivaOther
- Estimate amount of body fluid:
- Percutaneous (skin piercing)Mucous MembranesNon-Intact Skin
- Depth of Injury
- YesNo
- Area Covered
- Length of Time of Exposure
- Fresh cut (>24 hours)DermatitisChappedOther
- YesNo
- NoYes, Type:
- YesNo
- YesNo
- YesNo
- SECTION 4b - Exposure Testing
- N/AWas testedWas not tested (consent could not be obtained) / Date:
- HBVHIVN/AOther
- Employee consented to baseline blood collectionEmployee consented to serologic testing for HBVEmployee consented to serologic testing for HIV (sample is preserved for 90 days; employee must elect to have test conducted within 90 days)
- YesNo
- Name of clinic:
- If medical treatment is required, the physician will need to fax a completed Report of Workability form to 218-395-6325 after each visit. This form is available from your building secretary or can be found on the District website under Staff > Staff Resources > Forms > Business Office Forms > Worker's Compensation.
- No medical treatment needed at this timeOn-site treatment / First AidClinic / Hospital VisitChiropractorEmergency RoomHospitalizationOther
- Date of First Medical Treatment
  
  MonthDayYear
- Name and Address of Treatment Provider
  
  Treating Physician
  
  Street Address
  
  CityState / Province
  
  Postal / Zip Code
- Additional Notes:
- Have you experienced any lost time from work because of this injury or illness? If so, could you specify the dates and times?:
- Photo (optional)
- File Upload
  
  Cancelof
- Employee Signature*
  
  Clear
- Date
  
  MonthDayYear
- Please complete this form within 24 hours of an injury.
  
  Contact Ashley Rowland with any questions at 218-333-3100 x 31121 or ashley_rowland@isd31.net
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EMPLOYEE ACCIDENT

FIRST REPORT OF INJURY