ROANOKE PUBLIC LIBRARY
WORKERS’ COMPENSATION ACCIDENT/ILLNESS REPORT FORM
(for reporting work-related injuries/illnesses)
| The injured worker must complete and file this report with the Roanoke Public Library Director, 314 N. Main Street, Roanoke, IN 46783, WITHIN 24 HOURS of any on-the-job injury. |
| PART A: INJURED WORKER’S STATEMENT OF ACCIDENT/ILLNESS | ||||||||||
| Employee Name (Last Name):
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(First Name) | |||||||||
| Home address: | SSN: | |||||||||
| Home phone: | Date of Birth: | Work phone: | ||||||||
| Job Title: | Department Name: | |||||||||
| Date of occurrence: | Time of accident: | Location of injury occurrence: | ||||||||
| How was injury incurred: | Time employee began work:
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| Were you ever treated for a similar condition before: | Body part(s) injured: | |||||||||
| If yes, give details:
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Employee’s Signature:____________________________________________ Date:_____________________________ |
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| Part B: SUPERVISOR’S STATEMENT | ||||||||||
| Injury: | ||||||||||
| Name and address of hospital or physician: | Did injured worker receive medical treatment: | Date: | ||||||||
| Object or machinery causing injury:
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| Was there contact with any other person’s blood or body fluid:
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| If yes, name and address of source person: | Did weather conditions contribute to occurrence: | |||||||||
| How could a similar occurrence be avoided: | If yes, what were the weather conditions: | |||||||||
| Describe any unsafe practice: | ||||||||||
| Name and phone number of witnesses (if any): | ||||||||||
| Did injured worker lose time from work: | If yes, first full day of disability: | |||||||||
| Has the injured worker returned to work: | If yes, date returned: | |||||||||
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IF THE INJURED WORKER RETURNS TO WORK OR BECOMES DISABLED AFTER THIS FORM HAS BEEN FILED, IT IS IMPERATIVE THE LIBRARY BOARD OF TRUSTEES BE NOTIFIED. |
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| Supervisor’s Name: | Signature: | |||||||||
| Phone ext: | Date Completed: | |||||||||
Part A is to be completed by the injured worker immediately after he/she has reported any on-the-job injury to his/her supervisor. All questions must be answered. The employee’s signature is required.
Part A is to be verified by the Supervisor.
Part B is to be completed and signed by the supervisor. Discuss the occurrence in detail with the injured worker prior to completing this section. If you have any valid reason to believe the occurrence did not happen as described, use the word “Alleged” in your description of injury.
If you have any questions regarding the filing of this form, contact the Roanoke Public Library Board President.