NAME OF INJURED _________________________________________________________ HOME ADDRESS________________________________________________________
DATE OF BIRTH __________________ HOME TELEPHONE NO. _____________________ SOCIAL SECURITY NO. __________________________________ SEX: M
❐ F ❐
DISTRICT _________________________________________________________________JOB TITLE _______________________________ FULL TIME ❐ PART TIME ❐
DATE OF INJURY OR ILLNESS TIME OF DAY ________________ a.m. WAS EMPLOYEE UNABLE TO WORK? ❐ Yes, date last worked ______________
__________________________ ________________ p.m.
❐ No
HAS EMPLOYEE RETURNED TO WORK?
❐ Yes, date returned __________________ ❐ No, still off work DID EMPLOYEE DIE? ❐ Yes, date____________ ❐ No
DOES EMPLOYEE HAVE ANOTHER JOB? ❐ Yes ❐ No IF YES, WHAT IS THE NAME OF THE EMPLOYER? __________________________________________________
SUPERVISOR IN CHARGE WHEN ACCIDENT OCCURRED (ENTER NAME): ___________________________________________________________________________________
PRESENT AT ACCIDENT?
❐ Yes ❐ No WHEN DID SUPERVISOR FIRST KNOW OF INJURY? ________________________________________________________________
San Diego County Office of Education
Workers' Compensation JPA
SUPERVISOR'S REPORT OF ACCIDENT
Date of Hire ______________________
Type or use ball point pen and PRINT, PRESS HARD. Retain goldenrod copy for your file.
❐ SIDE OF BODY: ❐ LEFT ❐ RIGHT ❐ ABRASION
❐ BITE/STING
❐ BRUISE
❐ BURN
❐ CHEMICAL EXP.
❐ CUT
❐ DISLOCATION
❐ FOREIGN BODY
❐ OTHER (SPECIFY):
DESCRIPTION OF THE ACCIDENT
HOW DID ACCIDENT HAPPEN? WHAT SPECIFIC ACTIVITY WAS EMPLOYEE PERFORMING AT TIME OF INJURY? WHERE WAS EMPLOYEE?
SPECIFY MACHINE OR EQUIPMENT INVOLVED. _______________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
FIRST AID TREATMENT _________________ BY (NAME) ____________________________________________________________________________________________
SENT HOME _________________ BY(NAME) _____________________________________________________________________________________________
SENT TO HOSPITAL _________________ BY(NAME) ___________________________________ NAME OF HOSPITAL: ______________________________________
SENT TO SCHOOL NURSE _________________ BY(NAME) _____________________________________________________________________________________________
SENT TO PHYSICIAN _________________ BY(NAME) _________________________________ PHYSICIAN'S NAME: _____________________________________
INJURY LOCATION NATURE OF INJURYPART OF BODY INJURED
Carbonless Form
WHITE – District Office
CANARY – Administrator via District
PINK – Risk Mgmt/County Office of Ed.
GOLDENROD – Site of Accident
Date Employee Received *DWC Form 1 ______________ Date DWC Form 1 Returned _________________
SCHOOL ____________________________________________________ DEPARTMENT _______________________________ LOCATION NO. _________________________
SUPERVISOR NAME ________________________________________________________________________ TITLE __________________________________________________
SIGNED SUPERVISOR ______________________________________________________________________ DATE __________________________________________________
*DWC Form 1 is Employee's Claim for Worker's Compensation Benefits Form
Form 231 – Risk Management
San Diego County
Office of Education 2-10
❐ ATHLETIC FIELD/
COURTS
❐ BATHROOM
❐ BUS STOP
❐ CLASSROOM
❐ LOCKER ROOM
❐ LUNCH AREA
❐ OTHER
(SPECIFY):
❐ OFFICE
❐ PARKING LOT
❐ PLAYGROUND
❐ POOL
❐ ROADWAY
❐ SCIENCE LAB
❐ SHOP LAB
❐ SIDEWALK
❐ STAIRS
DEPARTMENT _____________________
❐ ANKLE
❐ ARM
❐ BACK
❐ CHEST
❐ CHIN
❐ EAR
❐ EYE
❐ FACE
❐ OTHER (SPECIFY):
❐ FINGER
❐ FOOT
❐ GROIN
❐ HAND
❐ HEAD
❐ HIP
❐ KNEE
❐ LEG
❐ MOUTH
❐ NECK
❐ NOSE
❐ SHOULDER
❐ STOMACH
❐ TOOTH
❐ WRIST
❐ FRACTURE
❐ INTERNAL
❐ NO VISIBLE INJURY
❐ PAIN
❐ PUNCTURE
❐ REDNESS
❐ SPRAIN/STRAIN
❐ SWELLING
❐ ANIMAL/INSECT
❐ ANOTHER STUDENT
❐ BUILDING
❐ CHEMICALS
❐ EQUIPMENT
❐ FENCE/GATE
❐ FOOD/DRINK
❐ FURNITURE
❐ OTHER (SPECIFY):
❐ HAND TOOL
❐ POLE
❐ POWERED TOOL
❐ SELF
❐ SURFACE
❐ THROWN OBJECT
❐ VEGETATION
❐ VEHICLE
CAUSE OF INJURY
HOW WAS EMPLOYEE INSTRUCTED TO PREVENT ACCIDENT FROM RECURRING?
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
WAS THERE A VIOLATION OF APPROVED SAFETY PRACTICES/STANDARDS? _____
IF YES, WHAT?
_____________________________________________________________________
____________________________________________________________________________________
WAS SAFETY DEVICE PROVIDED? ________________________________________
IF YES, WAS IT IN USE AT TIME? __________________________________________
NAMES, ADDRESSES AND TELEPHONE NUMBERS OF WITNESSES:
______________________________________________________________________
______________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
IMMEDIATE ACTION TAKEN
(PLEASE PRINT)
