Fillable Employees Report (Oral Roberts University)

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Employees Report (Oral Roberts University)

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EMPLOYEE’S INSTRUCTIONS &
RESPONSIBILITIES FOR ON-THE-JOB
INJURY/ILLNESS
Risk Management
Responsibility of the Employee and Instructions
All employees are required to report every work-related on-the-job injury or illness to his or her supervisor immediately.
Failure to promptly report a job-related injury is considered grounds for termination. Once the report is completed, the
employee is required to submit it to the supervisor. The supervisor will forward all documentation to Risk Management.
***Note: If the employee is seriously injured or ill, contact EMSA. This form can be completed at a later time.
Once the report is received by Risk Management, there will be follow-up call to the employee for purposes of further
investigation and directing care, if necessary. An insurance claim may be filed with the insurance carrier. If so, the
insurance carrier will follow-up with the employee promptly.
Should an employee seek medical attention, he or she is required to immediately provide documentation to the
supervisor and Risk Management regarding his or her ability to work. If the employee is unable to personally deliver
the treating physician’s status report, it can be faxed to Attn: Risk Management (918)495-7563 or mailed to Attn: Risk
Management, Oral Roberts University 7777 South Lewis Avenue Tulsa OK 74171.
Employees placed on “no work” status MUST keep Risk Management and the immediate supervisor informed of
absences, doctor’s appointments and medical progress that must be accompanied by documentation from the
treating physician. Employee’s returning to work from a “no work” status must provide documentation from the
treating physician regarding his or her ability to return to work. Should you have any further questions, please
contact Risk Management at (918)495-7560.
All documentation should be forwarded to Risk Management.
EMPLOYEE’S REPORT OF ON-THE-JOB
INJURY/ILLNESS
Risk Management
To be completed by the Employee only. Provide full details. Use ink only.
EMPLOYEE’S INFORMATION
Date Report Completed: / /
Employee’s Legal Name:
Title: Department Name:
Home Phone #: Department Phone #:
Department Fax #: Email:
Date of Birth: / / Gender: ☐ Male ☐ Female
Workdays (i.e. Mon – Fri): Schedule (i.e. 8am – 5pm): No. Hours Worked/Week:
Hourly Wage: Weekly Salary: Date of Hire:
Z#:
DESCRIPTION OF TIME AND LOCATION
Were you Performing Regular Job Duties? ☐Yes ☐No If yes, describe the assigned task you were performing at the time
of the incident.
a.m. a.m.
Time you Reported to Work? p.m. Date & Time of Incident: / /
p.m.
Location of the accident:
Address Area (loading dock, bathroom, etc.)
Last Day Worked? : / /
DESCRIPTION OF INJURY OR ILLNESS
Describe fully how the accident occurred (including events that occurred immediately before the accident).
What part(s) of your body was/were injured? What was the nature of the injury (i.e. bruise to left knee, cut to right index
finger)? BE VERY SPECIFIC.
When did you report the accident to your supervisor? (Please provide date & time): / / a.m. / p.m.
Type of Treatment Received: ☐First Aid ☐Medical ☐None
If First Aid, describe.
If Medical, provide date first treated & name and address of treating physician or hospital.
If No Treatment was received at the time of the injury, will you require medical attention? ☐Yes ☐No ☐Maybe
ADDITIONAL INFORMATION
Recommendation on how to prevent this accident from recurring:
Name of Supervisor Phone #
Please list any witnesses to the incident.
Name: Title: Phone:
Name: Title: Phone:
Name: Title: Phone:
I declare under penalty of perjury that I have examined all statements contained herein and to the best of my knowledge and belief,
they are correct and complete. Any person who commits Workers’ Compensation fraud, upon conviction, shall be guilty of a felony.
Employee Signature: Date:
Retain a copy of this Report and give the original to your Supervisor.
Rev. 4.3.14
Completed by Risk Management Office Only
Claim No. Adjuster Name Contact Info
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Completed 18 July 2020

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