"Accident Reporting & Treatment (Art) Form - Supervisor's Report of Injury - Wagner College"

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Accident Reporting & Treatment (
ART) Form  ‐ Part 1: Supervisor’s Report of Injury
 
 
Employee’s Name:  ________________________________________________
Marital Status:  ________________________________________
Home Address:  ___________________________________________________________________________________________________________
Emergency Contact #:  ______________________________________________
Home Phone:  ________________________________________
Work Location:  ___________________________________________________
Date Reported:  _______________________________________
Injury Date:  ___________________ 
Time:  _____________      AM    PM
Last Day Worked:  _____________________________________
 
Describe what employee was doing when injured and how the injury occurred (be specific about body part injured):   
________________________________________________________________________________________________________________________ 
When and to whom did the employee first report the incident:   
________________________________________________________________________________________________________________________ 
 
Witnesses:  ______________________________________________________________________________________________________________ 
 
Supervisor Signature:  _______________________________________________         
Date:  __________________________________________ 
 
I
R
 
NFORMATION 
ELEASE
Any information related to this injury will be used for the purpose of evaluating and handling my claim for injury as a result of an incident occurring on or about the above 
noted date of injury and for no other purpose now or in the future.  I hereby authorize (Employer) or any of its representatives to be furnished any information and 
facts regarding this injury including reports and records, results of diagnosis, treatment prognosis, estimates of disability and recommendations for further treatment. 
 
Employee Signature:  _________________________________________________ 
Date: __________________________________________ 
 
 
Name of Medical Provider:  ____________________________________________ 
 Arrival Time:  ___________________________________ 
Nature of Injury: 
New Injury 
No Injury/Illness found 
Recurrence/aggravation of existing condition 
 
Work‐related 
Non work‐related 
Not known 
Type of Injury/Illness: ________________________________________________________
Body part injured: _____________________________________
R
 
ECOMMENDATIONS
FOR WORK: 
FOR LIFTING: 
FOR PUSHING/PULLING 
POSITION LIMITATION 
 Regular Work 
 1‐5 lbs. 
LIMITED TO:
No repetitive motion 
 Restricted duty 
 6‐15 lbs. 
 1‐5 lbs.
    Body Part: 
 
 16‐25 lbs. 
 6‐15 lbs.
No reaching above shoulders 
 
 26‐40 lbs. 
 16‐25 lbs.
No reaching below waist 
 
 41‐50 lbs. 
 26‐40 lbs.
No repetitive stooping, twisting or bending
 
 Over 50 lbs. 
 41‐50 lbs.
No pinching or forceful gripping
0
 
No Lifting 
 Over 50 lbs.
Standing limited to   ______________       hrs
0
 
 
No Pushing/Pulling
Sitting limited to   ________________       hrs
Treatment:__________________________________________________________________________________________________________________________
Treatment Plan: _____________________________________________________________________________________________________________________
Follow up appointment on ________________________________
with: _________________________________________________________________
P
D
ATIENT
ISPOSITION
 Return to supervisor; no restrictions 
Return to supervisor; send home
 Return to supervisor; with restrictions for  _________________       days
Employee can return to work on  ________________________           (date)
Medical Provider Signature: ___________________________________________
Print Name: _________________________________________________________
SUPERVISOR
R
W
ETURN TO
ORK
The above mentioned restrictions (if applicable) have been reviewed and the employee:
 Returned to full duty; no restrictions 
 Has been placed in an appropriate transitional duty position 
 Was sent home per medical instructions 
 Other 
Supervisor Signature ______________________________________________
Date __________________________________________________
Employee Signature ______________________________________________
Date: _________________________________________________
 
 
Accident Reporting & Treatment (
ART) Form  ‐ Part 1: Supervisor’s Report of Injury
 
 
Employee’s Name:  ________________________________________________
Marital Status:  ________________________________________
Home Address:  ___________________________________________________________________________________________________________
Emergency Contact #:  ______________________________________________
Home Phone:  ________________________________________
Work Location:  ___________________________________________________
Date Reported:  _______________________________________
Injury Date:  ___________________ 
Time:  _____________      AM    PM
Last Day Worked:  _____________________________________
 
Describe what employee was doing when injured and how the injury occurred (be specific about body part injured):   
________________________________________________________________________________________________________________________ 
When and to whom did the employee first report the incident:   
________________________________________________________________________________________________________________________ 
 
Witnesses:  ______________________________________________________________________________________________________________ 
 
Supervisor Signature:  _______________________________________________         
Date:  __________________________________________ 
 
I
R
 
NFORMATION 
ELEASE
Any information related to this injury will be used for the purpose of evaluating and handling my claim for injury as a result of an incident occurring on or about the above 
noted date of injury and for no other purpose now or in the future.  I hereby authorize (Employer) or any of its representatives to be furnished any information and 
facts regarding this injury including reports and records, results of diagnosis, treatment prognosis, estimates of disability and recommendations for further treatment. 
 
Employee Signature:  _________________________________________________ 
Date: __________________________________________ 
 
 
Name of Medical Provider:  ____________________________________________ 
 Arrival Time:  ___________________________________ 
Nature of Injury: 
New Injury 
No Injury/Illness found 
Recurrence/aggravation of existing condition 
 
Work‐related 
Non work‐related 
Not known 
Type of Injury/Illness: ________________________________________________________
Body part injured: _____________________________________
R
 
ECOMMENDATIONS
FOR WORK: 
FOR LIFTING: 
FOR PUSHING/PULLING 
POSITION LIMITATION 
 Regular Work 
 1‐5 lbs. 
LIMITED TO:
No repetitive motion 
 Restricted duty 
 6‐15 lbs. 
 1‐5 lbs.
    Body Part: 
 
 16‐25 lbs. 
 6‐15 lbs.
No reaching above shoulders 
 
 26‐40 lbs. 
 16‐25 lbs.
No reaching below waist 
 
 41‐50 lbs. 
 26‐40 lbs.
No repetitive stooping, twisting or bending
 
 Over 50 lbs. 
 41‐50 lbs.
No pinching or forceful gripping
0
 
No Lifting 
 Over 50 lbs.
Standing limited to   ______________       hrs
0
 
 
No Pushing/Pulling
Sitting limited to   ________________       hrs
Treatment:__________________________________________________________________________________________________________________________
Treatment Plan: _____________________________________________________________________________________________________________________
Follow up appointment on ________________________________
with: _________________________________________________________________
P
D
ATIENT
ISPOSITION
 Return to supervisor; no restrictions 
Return to supervisor; send home
 Return to supervisor; with restrictions for  _________________       days
Employee can return to work on  ________________________           (date)
Medical Provider Signature: ___________________________________________
Print Name: _________________________________________________________
SUPERVISOR
R
W
ETURN TO
ORK
The above mentioned restrictions (if applicable) have been reviewed and the employee:
 Returned to full duty; no restrictions 
 Has been placed in an appropriate transitional duty position 
 Was sent home per medical instructions 
 Other 
Supervisor Signature ______________________________________________
Date __________________________________________________
Employee Signature ______________________________________________
Date: _________________________________________________