Fillable Supervisor Workers Compensation Instructions (Andrews University)

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Supervisor Workers Compensation Instructions (Andrews University)

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Supervisor Workers’ Compensation Instructions
When an employee gets hurt on the job, please follow these steps:
1. Assess the situation. Does the employee need to go to the doctor?
a. If the employee needs to see a doctor, call University Medical Specialties (269-473-2222) and inform
them that the employee will be arriving for treatment.
NOTE: When the employee goes to University Medical Specialties, they MUST
inform the medical center that this is a Workers’ Compensation case. If the
employee chooses not to go to University Medical Specialties and/or does not
inform them their injury is work related, then payment under Workers’
Compensation insurance can be refused. If the employee is hurt after University
Medical Specialties hours, an on-call doctor can be reached by calling 269-473-
2222. The option of the walk-in clinic or emergency room is also available but only
in case of life-threatening situations.
b. If the employee does not need medical attention, administer first aid, if necessary, and follow steps 3
and 4.
2. As soon as possible, call Workers’ Compensation (269-471-3886) and relate the situation and action being taken.
3. Fill out the supervisor’s report (SARF) on line at: http://www.andrews.edu/HR/documents/sarf.pdf
4. Submit completed form to both the Workers’ Compensation office and the Office of Campus Safety.
5. If the doctor informs the employee that work needs to be missed or restricted because of the work related
injury or illness, any paperwork from the doctor to indicate missed or restricted work MUST be forwarded to the
Workers’ Compensation office.
6. If an employee has missed any work due to the work related injury or illnesses please contact the Workers’
Compensation office before submitting time to Payroll.
7. Each day/week that the employee is out of work needs to correspond directly with a doctor’s order for the
missed/restricted work. Any note, bills, or correspondence from or to the doctor or employee MUST be
forwarded to the Workers’ Compensation office.
8. When the employee is ready to return to work or released from restricted duty; the employee must provide a
return to work (RTW) note from their doctor. The RTW MUST be forwarded the Workers’ Compensation office.
Please inform the Workers’ Compensation office of any changes in the employee’s situation or condition as soon as
possible.
Your assistance aids both the Workers’ Compensation office as well as the employee in returning to normal work
conditions quickly.
Thank you,
Workers’ Compensation Office
Human Resources – 0840
Tele 269-471-3886
Fax 269-471-6293
workcomp@andrews.edu
Office Of Human Resources Supervisor Accident Report Form
Handling Instructions
This form is to be completed in response to an injury or a near miss accident that affected an Andrews University employee.
Form Completion Glossary
Date of injury: Date of employee’s injury
Location: Where the employee was when they were injured
Employee name: Name of injured employee
Supervisor name: Name of employee’s supervisor
Date injury reported: Date when the employee reported the accident to their supervisor.
Was the employee clocked in at the time of injury? Auto filled for hourly, if they clocked-in. Y/N for a salaried employee.
Where was the employee injured (anatomical location)? Part of body affected by injury
What was the type of injury? Use the pre-selected responses to identify the type of injury the employee sustained.
What was the extent of the injury? Use the pre-selected responses to identify the extent of injury the employee sustained.
What substance/object directly harmed/injured the employee? What caused the injury.
Did anyone witness the accident? If someone observed the accident/injury.
Witness name: Name of person who witnessed the accident when it occurred.
Additional Information
For additional instructions regarding worker's compensation and the role of a supervisor please go to the following website:
Contact Information
The Office Of Human Resources website can be found at: www.andrews.edu/hr
The Office Of Campus Safety's website can be found at: www.andrews.edu/safety
The MIOSHA 24hr. Fatality Hotline can be reached by phone at 1-800-858-0397
The Office Of Campus Safety can be reached by phone at 269-471-3321 or by email at safety@andrews.edu
If an employee’s injuries result in the death of the employee, the Office of Human Resources must be alerted immediately (or
the Office Of Campus Safety after business hours).
Accident Type: If employee was treated, click on the pre-selected response, Injury . If they were not treated, click on the pre-
selected response, Near Miss – No injury .
The information in this completed form contains private information and should be considered peronsal and confidential.
This form, once completed, should only be handled by the supervisor of the injured employee and should be submitted
directly to the Office of Human Resources and the Office of Campus Safety.
www.andrews.edu/services/hr/documents/workcomp/swcinstructions.pdf
Was the employee performing a work related function at the time of injury? Was the task a normal function of their position?
How was the employee injured? What the employee was doing when the injury occurred.
The Office Of Human Resources can be reached by phone at 269-471-3886 or by email at workcomp@andrews.edu
Office Of Human Resources Supervisor Accident Report Form
General
Date of Injury: Time of Injury: Location:
Injured Employee
Employee Name: AUID#: DOB:
Gender: Local Phone: Classification:
Department of Employment: Job Title: Years In Position:
Reporting Supervisor
Supervisor Name: AUID#: DOB:
Local Phone: Supervisory Level:
Department of Employment: Job Title:
Did the Reporting Supervisor Witness the Accident? Yes No N/A
Injury
Accident Type: Date Injury Reported:
Was the employee clocked in at the time of injury? Yes No N/A
Was the employee performing a work related function at the time of injury? Yes No N/A
Where was the employee injured (anatomical location)?
What was the type & extent of injury?
What substance/object directly harmed/injured the employee?
How was the employee injured?
Did anyone else witness the accident? Yes No N/A
Witness Name: AUID#: DOB:
Witness Local Phone:
Injury Analysis
Was the employee trained to perform the work-related task?
Yes No N/A
Was the employee performing the work-related task as they were trained? Yes No N/A
Was the work-related function evaluated for any hazards? Yes No N/A
Were safe guards provided to protect the employee from the hazards? Yes No N/A
Was the work-related function evaluated for personal protective equipment (PPE)? Yes No N/A
Was the employee equipped/supplied with required PPE? Yes No N/A
Was the employee using the PPE at the time of the injury? Yes No N/A
F
Classification
Supervisor Level
1 Type
2 Extent
Reset Form
Office Of Human Resources Supervisor Accident Report Form
Medical Treatment
Was Campus Safety contacted? Yes No N/A
Was first aid provided? Yes No N/A
Did the employee go to University Medical Center? Yes No N/A
If so, what was the name of the treating physician?
Was an ambulance requested? Yes No N/A
Did the ambulance treat the employee? Yes No N/A
Did the employee go to the Emergency Room? Yes No N/A
What hospital did the employee go to?
Miscellaneous
Did the employee resume work immediately after the accident? Yes No N/A
Was anyone else injured? Yes No N/A
If so, do they work for the same department? Yes No N/A
Was an Accident Report Form completed for any additionally injured employee? Yes No N/A
Were measures taken to prevent any future injury to the injured employee? Yes No N/A
If so please describe the measures taken.
Were measures taken to prevent any future injury to other employees? Yes No N/A
If so please describe the measures taken.
The form is to be filled out in its entirety. By submitting this form, the supervisor states that
all the information contained in the form is accurate to the best of their knowledge.
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Supervisor Workers Compensation Instructions (Andrews University)

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Completed 16 August 2020

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