Employee Leave Request Form



|[pic] | |

| |Incident / Accident / Variance Report |

This report serves as a loss control and quality improvement tool. The person most closely involved or the person discovering the incident, accident, or variance should immediately notify the Safety Officer (Director of HR); complete this form as soon as possible, and route it to HR.

| |      | | |      |

|1st Name: | | |Last Name: | |

|Street |      | | |      |

|Address: | | |City, State, Zip: | |

| |      | |Individual | Patient Member |

|Phone: | | |Affected: |Employee Other |

|Incident |      | | |      | |      | |

|Location: | | |Date/Time: | | | |a.m. p.m. |

Description of Incident Type of Injury or Illness

| Struck by object | | Abrasion/scratch/scrape | | Concussion |

|Striking against object | |Cut/laceration | |Amputation |

|Fall or slip | |Puncture Wound | |Burn (thermal) |

|Strain | |Bump/bruise/contusion | |Burn (chemical) |

|Caught in, on, or between | |Sprain/Strain | |Rash dermatitis |

|Contact with temperature extremes | |Fracture | |Foreign body |

|Inhalation, absorption, swallowing | |Dislocation | |Electric Shock |

|Other: | |Hernia | |Other: |

Patient / Member / Employee Related Factors Part of Body Affected

| Aphasic | | Improper footwear | | Head | | Upper Back |

|Bowel/Bladder Issue | |Unsafe body mechanics | |Face | |Abdomen |

|Blind | |Unexpected move | |Eye Left Right | |Middle Back |

|Hearing impaired | |Visitor helping client | |Ear Left Right | |Lower Back |

|Language barrier | |Horseplay | |Neck | |Pelvis |

|Confused/Disoriented | |Seeking attention | |Shoulder Left Right | |Buttocks |

|Mental Status | |Failed to keep appt. | |Arm Left Right | |Groin |

|Unable to follow orders | |Did not make appt. | |Elbow Left Right | |Leg Left Right |

|Refused to follow orders | |Inefficiency | |Wrist Left Right | |Knee Left Right |

|Medical condition | |Didn’t follow rules | |Hand Left Right | |Ankle Left Right |

|Surgical condition | |Not applicable | |Fingers Left Right | |Foot Left Right |

|Incorrect info from patient | | | |Chest | |Toes Left Right |

|Other: | | | |Other: | | |

Physical Facility, Equipment or Supplies Involved Severity of Injury & Treatment

| Bathroom | | Treatment table | | No apparent injury (no injury of any type is noted) |

|Floor/hallway | |Ultrasound unit | |Minor (injury is temporary; doesn’t cause further complications) |

|Lighting | |Traction unit | |Major (injury is serious, causing considerable discomfort, requiring extended treatment |

|Electrical device | |Whirlpool | |or is life threatening) |

|Parking lot/sidewalk | |Hydrocollator | |Indeterminable (impossible to determine the extent of injury relating to the |

|Chair/wheelchair | |Office machines | |incident/occurrence) |

|Crutches/walker/cane | |Equipment cart | |Not applicable |

|Safety equipment | |Accessories/supplies | | |

|Fire extinguisher | |Not involved | |Treatment |

|Other: | | | |Referred for treatment |

| | | | |Refused Treatment Not Applicable |

| | | | |Other: |

|[pic] | |

| |Narrative of Incident, Accident or Variance |

Write a description of what happened. (Please note this field will expand as you type into it.)

|      |

Signatures

|Employee/Patient/Member/Other: |      | |Date: |      |

|Witness: |      | |Date: |      |

|Clinical Director: |      | |Date: |      |

|Safety Officer: |      | |Date: |      |

Be sure to immediately notify the Safety Officer (HR Director) in the event of any situation involving injury. This completed report should be given to the Safety Officer. It will ultimately be routed to the Clinical Director; then filed and reviewed quarterly by the Safety Committee.

-----------------------

Admin/HR, Incident, Accident, Variance Report: 1/09

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download