First Report of Injury Form

Alief ISD Workers’ Compensation First Report of Injury Form
Name: Last, First, M.I*
Employee ID # or SSN*
Date of Birth*

MonthDayYear
Date
Home Address*

Current Mailing Address (Street or PO Box)

Street Address Line 2

CityState

Zip Code
Cell Phone*
Email - the best email to reach you
example@example.com
Job Title*
Gender*

MaleFemale
Campus/Department*
Supervisor’s Name
Do you speak English?*

YesNo
If you don't speak English, specify language
Date Injury Occurred*

MonthDayYear
Date
Time Injury Occurred*

Hour Minutes

AM/PM Option
Return to Work Date

MonthDayYear
Date
Are you off Work?*

YesNo
Campus / Department where injury occurred*
Where exactly did this happen? Class, hall, etc*
How did the injury occur?*
What body part(s) were injured? *
Who witnessed the accident? (Who saw, heard, or was first on the scene?)*
What were you doing when the injury occurred?*
Medical treatment is available through our 504 Network. Will you be seeking medical treatment?*

YesNoUndecided
Any Additional Comments:
Injured Employee’s Signature: *

Clear
Today's date: *

MonthDayYear
Date
Employee Acknowledgement of the Alliance Direct Contracting Program
Alief ISD is part of TASB's Alliance Network of doctors. I have received information that tells me how to get health care under my employer’s workers’ compensation coverage. If I am hurt on the job and live in a service area described in this information, I understand that:
1. I must choose a treating doctor from the Alliance list of doctors designated as treating doctors. 2. I must go to my treating doctor for all health care for my injury. If I need a specialist, my treating doctor will refer me. If I need emergency care, I may go to any licensed medical professional within the United States. 3. Even though my treating doctor should refer me to a specialist of providers contracted with the Alliance, I understand that I need to verify that the referral doctor is a member of the Alliance provider panel. 4. The Texas Association of School Boards Risk Management Fund will pay the treating doctor and other Alliance providers for all health care related to my compensable injury. 5. I understand that my medical and/or income benefits may be disputed if I receive health care from a provider other than an Alliance provider withDateout prior approval from the Fund. 6. Making a false or fraudulent workers’ compensation claim is a crime that may result in fines and or imprisonment. 7. If I want to change doctors after my first choice, I can do so within the first 60 days of starting treatment, and I can only choose from the Alliance list of providers. A third choice requires approval from my adjuster.*

Clear
Date:

MonthDayYear
Date
Direct contracting service areas are subject to change. To locate a treating doctor within your area, please review the WC Packet with a list of local doctors given to you by the nurse, secretary or your supervisor. You may also visit the PSWCA web site at pswca.org or call your adjuster at 800.482.7276.
If I am absent from duty because of a job-related illness or injury, I understand that I am not eligible for workers' compensation weekly income benefits until my absence exceeds seven calendar days. I understand that if I am not absent more than seven calendar days, the district will use whatever sick leave days I have available to pay me. If I am absent more than seven calendar days, I have a choice on how I am to be paid.
I choose the following option for pay:*

I choose to use only a designated number of days.I choose to use all available paid leave. I understand that I will not receive workers' compensation weekly income benefits until I have exhausted all of my paid leave.I choose NOT to use any available paid leave at this time. I understand that I will not receive any regular salary payments from Alief ISD while receiving weekly income benefits under workers' compensation. No available paid leave will be deducted from my leave balance. I further understand that by selecting this option, I will receive only workers' compensation wage benefits for any absences resulting from my work-related illness or injury, unless and until I communicate to the district a change in my decision.
You chose to use only a designated amount of days. Below, type in the number of sick leave days you would like to use before workers' comp benefits begins. *
Signature*

Clear
Date

MonthDayYear
Date
Should be Empty:

Alief ISD Workers’ Compensation First Report of Injury Form

Employee Acknowledgement of the Alliance Direct Contracting Program