How to Complete a Supervisors Accident Packet

1
How to Complete a Supervisors Accident Packet
2
The Accident
3

John Doe
000000
123-45-6789
[phone]
[phone]
DDR
10 23 2006 12 05
Step 1
10 23 2006 12 15
Paul Garcia
[phone]
English
White
Other
13.00 520.00
840.00 80
8 5
10 1
11 3

Concentra
Jane Doe
[phone]
4
Employee States I was walking down the hall with
Jane Doe and when I turned the corner I fell over
the boxes stacked in the hall hurting my knee and
back. Supervisor States Employee was walking
down hall, talking to Jane Doe. After
conversation ended, Jane doe continued forward
through doorway and John Doe continued around the
corner colliding with stacked boxes against the
left side of the hallway, falling to the floor on
his left knee and back. Why Boxes placed in
unsafe location and employee not paying attention
to his surroundings
Step 1
Left Knee Low Back
Trip and Fall
611 Walker St. 6th Floor
Hallway
Walking and talking to Co-worker
N/A
Boxes
Paul Garcia
Supervisor
10-23-2006
John Doe
10-23-2006
5
Step 2
JD
JD
JD
JD
Employee's Copy
JD
JD
JD
JD
JD
JD
JD
JD
JD
000000
10 - 23 - 2006
John Doe
10-23-2006
Paul Garcia
10-23-2006
6
John Doe
Step 3
John Doe
10-23-2006
John Doe
123 Houston St. Houston, TX 77002
[phone]
123-45-6789
7
Step 4
8
Step 5

Employee States I was walking down the hall with
Jane Doe and when I turned the corner I fell over
the boxes stacked in the hall hurting my knee and
back. Supervisor States Employee was walking
down hall, talking to Jane Doe. After
conversation ended, Jane doe continued forward
through doorway and John Doe continued around the
corner colliding with stacked boxes against the
left side of the hallway, falling to the floor on
his left knee and back. Why Boxes placed in
unsafe location and employee not paying attention
to his surroundings
John Doe
000000
123-45-6789
10 23 2006 12 05
[phone]
[phone]
DDR
10 23 2006 12 15
Paul Garcia
[phone]
Left Knee Lower Back
13.00 520.00
English
White
Other
840.00 80
8 5
10 1
11 3
Trip and Fall

Concentra
Jane Doe
[phone]
611 Walker St. 6th Floor
Hallway
Walking and talking to Co-worker
N/A
Boxes
Paul Garcia
Supervisor
10-23-2006
John Doe
CC5555
10-23-2006
9
Step 6
Forms to Forward to Your DDR