Employee Safety Incident Report Form - Maine

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Employee Safety Incident Report
PURPOSE: This form is to be used by employees to document their workplace illnesses and injuries.
INSTRUCTIONS:

For serious life or limb threatening injuries, call 911 or go to the nearest Emergency Room, and
report the injury after the situation has stabilized.

Promptly report all workplace injuries & illnesses to your supervisor AND the Human Re-
source Manager—even if first aid or medical care is not required.

Complete this form, and give it to Human Resources within 1 business day of the incident.

If a consumer was involved, (1) report the incident to your supervisor, (2) do not identify the con-
sumer by name in this report and (3) complete a separate consumer incident report.

If medical attention is required, Human Resources will arrange care through Concentra; as a gen-
eral rule, you should not [initially] see your own doctor for work-related injuries.
EMPLOYEE INFORMATION
Name:
Job Title:
Date of Birth:
Hire Date:
INCIDENT INFORMATION
Date of Incident:
Time of Incident:
Shift Start Time:
Location of Incident:
INCIDENT DESCRIPTION
What were you doing just before the incident occurred?
What happened?
What is the nature of the injury or illness?
What object or substance directly harmed you?
Employee Safety Incident Report
PURPOSE: This form is to be used by employees to document their workplace illnesses and injuries.
INSTRUCTIONS:

For serious life or limb threatening injuries, call 911 or go to the nearest Emergency Room, and
report the injury after the situation has stabilized.

Promptly report all workplace injuries & illnesses to your supervisor AND the Human Re-
source Manager—even if first aid or medical care is not required.

Complete this form, and give it to Human Resources within 1 business day of the incident.

If a consumer was involved, (1) report the incident to your supervisor, (2) do not identify the con-
sumer by name in this report and (3) complete a separate consumer incident report.

If medical attention is required, Human Resources will arrange care through Concentra; as a gen-
eral rule, you should not [initially] see your own doctor for work-related injuries.
EMPLOYEE INFORMATION
Name:
Job Title:
Date of Birth:
Hire Date:
INCIDENT INFORMATION
Date of Incident:
Time of Incident:
Shift Start Time:
Location of Incident:
INCIDENT DESCRIPTION
What were you doing just before the incident occurred?
What happened?
What is the nature of the injury or illness?
What object or substance directly harmed you?
Was any first aid administered?
Yes
No
If yes, explain:
Could this incident have aggravated a pre-existing condition or prior injury?
Yes
No
If yes, explain:
Was a consumer incident report filed?
Yes
No
EMPLOYEE SIGNATURE
I affirm that the details provided in this report are true and accurate to the best of my knowledge. I under-
stand that intentionally providing false or misleading information may constitute fraud and could result in
criminal charges and/or disciplinary action, up to and including termination of my employment.
_______________________________________
_______________________________________
Employee Signature
Date
***Do Not Write Below This Line -- HR Use Only***
Date Report Received By HR:
Date Reported to MEMIC:
MEMIC Claim #:
HR Signature:
Medical Care
Declined
First Aid: ____________________________________________________________________________
Emergency Room: ____________________________________________________________________
____________________________________________________________________________________
Concentra: __________________________________________________________________________
____________________________________________________________________________________
Other: ______________________________________________________________________________
____________________________________________________________________________________
Did the employee miss any work because of this injury?
Yes
No
If yes, explain.
Notes:

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