Staff Reporting Form

Type of Report Being Submitted
This form is to report a staff (team member) injury, illness or accident that has occurred, including instances where professional medical attention is not needed. This form must be submitted within 24 hours of the date of the injury, illness or accident.
INSTRUCTIONS: Please complete the General Information, the Illness, Injury, or Accident Details, and the Medical Response/Treatment Sections with the Staff (Team Member) present and have them sign the form at the end of the Medical Response/Treatment Section.
GENERAL INFORMATION
Name of Staff (Team Member) with injury, illness or accident:

First NameLast Name
Date of birth for Staff (team member) with injury, illness or accident:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Cell Phone Number of Staff (team member) with injury, illness or accident:
Please enter a valid phone number.Format: (000) 000-0000.
Home Address of Staff (Team Member) with Injury, Illness or Accident:

Street Address

Street Address Line 2

CityState

Zip Code
Position Title of Staff (team member) with injury, illness or accident:
Hire Date of Staff (Team Member)

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Please select the STATE where the Injury, Illness or Accident occurred:
Please select the DISTRICT where the Injury, Illness or Accident occurred:
Please select the SITE LOCATION where the Injury, Illness or Accident occurred:
Gender of Staff (team member) with injury, illness or accident:
Employment Status of Staff (team member) with Injury, Illness or Accident:
Email of Staff (team member) with injury, illness or accident:
example@example.com
ILLNESS, INJURY OR ACCIDENT DETAILS
Date injury/illness or accident occurred:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Date injury/illness or accident was reported to AlphaBEST:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Injury/Illness or accident location: (For example, classroom, cafeteria, playground, other - please specify.)
Time of injury/illness or accident

Hour Minutes

AM/PM Option
Time Staff (team member) reported to work

Hour Minutes

AM/PM Option
Did injury/illness or accident happen on employer premises?
Please describe how the injury occurred and be as specific as possible. Describe machines, parts, objects, tools, materials and other important details.
Potential Team Member Witnesses - List all persons who may have knowledge of this situation and their contact information (phone number, best time to reach them, etc.)
Part of Body Injured (Check all that apply):
If Other was selected for Area of Injury/Illness, please describe below.
Nature of Injury, Illness or Accident:
If Other was selected for the nature of the Injury, Illness or Accident please describe below.
MEDICAL RESPONSE/TREATMENT
What type of response was needed for the injury/illness or accident ?
If emergency medical care was required, which type of care did the staff seek:
If emergency care was required, please list the name and address of doctor or facility. If not known, please type unknown in the box below.
Please provide any other relevant details. If none, type N/A.
If Staff (Team Member) refused treatment, please state the reason. If this doesn't apply, please type N/A.
Signature of Staff (team member) reported in this Injury, Illness and/or Accident Form:
SUPERVISOR/MANAGER REPORT

This section should be completed by the Supervisor or Manager of the person involved in the Illness, Injury, or Accident.
Date of Investigation into this Illness, Injury, or Accident:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Who performed the Investigation? (List Name and Position Title)
Name of the Supervisor/Manager of Staff (Team Member) involved:

First NameLast Name
Phone Number of the Supervisor/Manager of Staff (Team Member) involved:
Please enter a valid phone number.Format: (000) 000-0000.
Who was immediately in charge at the time of the illness, injury or accident? Please list first and last name.
Was the illness, injury or accident a result of a problem with equipment or tools?
If tools or equipment were used, was the staff (team member) trained on the equipment or tools?
If the staff (team member) was not trained, please explain.
Please list the type of tool, model and manufacturer of the tool.
Describe any damage to the equipment. If note, please type N/A.
This Illness, Injury or Accident happened as a result of:
If Other was selected, please describe below.
This Illness, Injury or Accident could be prevented in the future by:
If Other was selected, please describe below.
Briefly and specifically state how the above recommended safety preventions will be implemented.
Upload Any Additional Documentation (Witness Statements, Incident Questionnaires, etc.)

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Name of person submitting this Staff Illness, Injury or Accident form:

First NameLast Name
Position Title of person submitting this Staff Illness, Injury or Accident form:
Email of Person Submitting this Staff Illness, Injury or Accident Form
example@example.com
Signature of person submitting this form
This form is to report any staff incident of inappropriate discipline from a team member to a student(s). Examples include corporal punishment of any kind (spanking, slapping, jerking, pinching, pulling body parts), using physical restraints and general inappropriate discipline such as isolation or verbal abuse. This form must be submitted within 24 hours of the date of the incident.
Name of Staff (Team Member) involved in Incident:

First NameLast Name
Position Title of Staff (team member) involved in Incident:
Home phone number of staff (team member) involved in Incident:
Please enter a valid phone number.Format: (000) 000-0000.
Please select the STATE where the Incident occurred:
Please select the DISTRICT where the Incident occurred:
Please select the SITE LOCATION where the Incident occurred:
Incident location: (For example, classroom, cafeteria, playground, other - please specify.)
Nature of Incident:
If Other was selected for the incident please describe below.
Please describe how the incident occurred and be as specific as possible. Describe who, what, when, where and how as well as any other important details.
For this instance, was Licensing made aware of this situation?
For this instance, was CPS (Child Protective Services) made aware of this situation?
Potential Team Member Witnesses - List all persons who may have knowledge of this situation
Please provide any other relevant details. If none, type N/A.
Upload Any Additional Documentation (Witness Statements, Incident Questionnaires, etc.)

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Name of person submitting this Incident form

First NameLast Name
Position Title of person submitting this Incident form:
Email of person submitting this Incident Form
example@example.com
Signature of person submitting this Incident Form
ADA Reasonable Accommodation Request Form and Release of Information

This form is for AlphaBEST Team Members who would like to request consideration of a reasonable accommodation in order to perform the essential functions of the job. Once the form is completed and submitted, it will be routed to our Human Resource department for review and you will be contacted for more information and/or once a determination has been made. Privacy Note: Your information will be held in confidence and only shared with those who need to know.
Name of Team Member completing this form:

First NameLast Name
HR Notes:
Today's Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Your Work Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Your Personal Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Your Email Address (where we can contact you):
example@example.com
Your Position Title:
Please select the STATE in which you work:
Please select the DISTRICT in which you work:
Please select the SITE LOCATION in which you work:
Name of Your Immediate Supervisor

First NameLast Name
Have you reviewed your most recent job description?
If you have not reveiwed your most recent job description, please ask your immediate manager to provide it for you before submitting this request.
NATURE OF THE QUALIFYING DISABILITY:
Please describe the nature, extent and duration of your disability.
REQUESTED ACCOMMODATION: Please describe the accommodation(s) you believe is needed to enable you to perform the essential functions of this job.
PHYSICIAN CONTACT INFORMATION: Please provide name, address, telephone and fax numbers. The physician may receive a letter/fax from us requesting information on your impairment/disability and recommendation(s) for accommodation(s)
ACKNOWLEDGEMENT & RELEASE: I authorize the release of necessary confidential medical information regarding my disability to relevant hiring managers as deemed necessary by Human Resources. I also attest to the fact that a copy of the job description has been given to me for review and reference. My signature below also authorizes a representative of AlphaBEST to contact my physician (via fax, mail or over the phone) to obtain the facts necessary to consider this request. I understand that an interactive discussion requires sufficient information to make a determination and without my permission, the request may be denied.
Signature
Should be Empty:

This form is to report a staff (team member) injury, illness or accident that has occurred, including instances where professional medical attention is not needed. This form must be submitted within 24 hours of the date of the injury, illness or accident.

GENERAL INFORMATION

ILLNESS, INJURY OR ACCIDENT DETAILS

MEDICAL RESPONSE/TREATMENT

SUPERVISOR/MANAGER REPORT

ADA Reasonable Accommodation Request Form and Release of Information