Fillable Supervisor Report (Oral Roberts University)

Fill Online, Printable, Fillable, Blank Supervisor Report (Oral Roberts University) Form

Use Fill to complete blank online ORAL ROBERTS UNIVERSITY pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Supervisor Report (Oral Roberts University)

On average this form takes 17 minutes to complete

The Supervisor Report (Oral Roberts University) form is 3 pages long and contains:

  • 0 signatures
  • 0 check-boxes
  • 69 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Oral Roberts University

BROWSE ORAL ROBERTS UNIVERSITY FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
SUPERVISOR’S INSTRUCTIONS &
RESPONSIBILITIES FOR ON-THE-JOB
INJURY/ILLNESS
Risk Management
Reporting an injury
I. When an employee reports a work-related injury or illness, direct him/her to complete an Employee Report for On-
The-Job Injury/Illness. If The Employee Is Seriously Injured Or Ill, Contact EMSA Immediately. This Form Can Be
Completed At A Later Time.
***Note: This document can be found on the Faculty and Staff Intranet Site. See instructions below.
1. Click on Human Resources.
2. Select Risk Management.
3. Then, select the Risk Management tab on the left.
4. Click on Worker’s Compensation.
5. The Employee’s Report of On-the-Job Injury/Illness can be found near the bottom
of the page.
6. Click on the link and complete the form.
II. Contact Risk Management at (918)495-7560 to report the injury.
• The purpose for immediate notification is so that the Risk Management can verify occurrences of a work-
related injury/illness and direct the employee to the Preferred Occupational Health Facilities.
• If Risk Management has no knowledge of the injury or illness, then the injured employee may be kept waiting
for medical attention until the supervisor can be located and the injury is verified.
III. Complete the Supervisor Report for On-The-Job Injury/Illness.
IV. Submit both Employee & Supervisor reports to Risk Management at riskmanagement@oru.edu
or via fax to
(918)495-7563 within the first 24 hours of notification. Please Do NOT Include Instruction & Responsibilities
Pages.
Responsibility of the Employee
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. 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 the immediate supervisor and Risk Management informed of absences,
doctor’s appointments and medical progress. If the supervisor and/or Risk Management have not received periodic
updates from the employee accompanied by treating physician documentation, it is the supervisor’s responsibility to
contact the employee. If the employee cannot be reached and has not returned to work, please contact Risk Management
at (918)495-7560. 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.
Any hours missed from work must be reported on Kronos Timekeeping System using pay code WCC, unless otherwise
advised by Risk Management. If you have any questions, please call Risk Management at (918)495-7560.
All documentation should be forwarded to Risk Management.
SUPERVISOR’S REPORT OF ON-THE-JOB
INJURY/ILLNESS
Risk Management
To be completed by the immediate supervisor or manager only. Provide full details. Use ink only.
SUPERVISOR’S INFORMATION
Date Report Completed:
Immediate Supervisor Name:
Title: Department Name:
Supervisor Signature:
Supervisor Phone #: Department Phone #:
Department Fax #: Supervisor’s Email:
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’S INFORMATION
Employee’s Name:
Title: FTE:
Workdays (i.e. Mon – Fri): Schedule (i.e. 8am – 5pm): No. Hours Worked/Week:
Employee’s Z#:
Was the Employee Performing Regular Job Duties? ☐Yes ☐No If yes, describe the assigned task the employee
was performing at the time of the incident.
DESCRIPTION OF INJURY OR ILLNESS
Date & Time of Incident: / / a.m. / p.m Date & Time Reported: / / a.m. / p.m.
Was the incident on premises? Where did it occur?
What part(s) of the employee’s body was injured? What was the nature of the injury (i.e. bruise to left knee, cut to right index
finger)? BE VERY SPECIFIC.
Type of Treatment Received: ☐First Aid ☐Medical ☐None
If First Aid, describe.
If Medical, provide Name and Address of Doctor or Hospital.
Describe fully how the accident occurred (including events that occurred immediately before the accident).
What exactly contributed to the physical injury or illness?
Any prior physical conditions? ☐Yes ☐No If so, explain.
Were safety procedures followed? ☐Yes ☐No ☐N/A
Was the employee trained to follow proper safety procedures? ☐Yes ☐No ☐N/A
Were there any environmental hazards? If so, explain.
Did the assignment require special protective equipment? If so, describe.
Was the employee wearing or using the protective equipment? ☐Yes ☐No
If safety procedures were not followed, describe the supervisor’s corrective action.
How could this incident be prevented in the future?
Are there any doubts to the validity of this injury or illness? If so, please explain.
If required, is there modified duty available? ☐Yes ☐No
Additional comments:
ADDITIONAL INFORMATION
Please list any witnesses to the incident:
Name: Title: Phone:
Name: Title: Phone:
Name: Title: Phone:
If witnesses were present, please attach witness statements with your report to Risk Management.
Retain original reports in Employee’s file. Rev. 4.3.14
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Supervisor Report (Oral Roberts University)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 18 July 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document