Employee Injury

If an employee is injured on the job or have a job- related illness, the following guidelines must be followed.

  1. The employee will complete the Employee’s Report of Injury Form.
  2. The employee will tell the supervisor about the injury or illness (MUST be done by the end of the shift).
  3. The employee will go to Employee Health and Wellness for care.
  4. The employee will go to the SAMC Emergency Department if the injury is urgent/life threatening or if Employee Health and Wellness is NOT open.

NOTE:  If the employee goes to the SAMC Emergency Department, they should call Employee Health and Wellness as soon as they are open to report the injury or illness.

  1. The employee will give the supervisor the Employee’s Report of Injury Form after it has been filled out.
  2. The supervisor will investigate the accident. The supervisor will complete their portion of the Employee’s Report of Injury Form.
  3. The employee must submit the completed Employee’s Report of Injury Form to Employee Health and Wellness within 24 hours of the injury.
  4. The employee will receive a detailed written statement (Work Status Form). This form will explain any work restrictions and/or modifications.  It is the responsibility of the EMPLOYEE to tell the supervisor about any work restrictions and/or modifications.
  5. Employees should NOT go to their personal health care provider.
  6. Those who do not follow these instructions may lose the benefits for Workers’ Compensation.

 

Employee’s Report of Injury Form: 

  • See below
  • To be completed by employee and supervisor
  • Copies to employee, supervisor and EH&W

Work Status Form (May only be located in EH&W/SAMC Emergency Dept.):

  • To be completed by health care provider
  • To be signed by employee and supervisor
  • Copies to employee, supervisor and EH&W

Form PDFs: