Accident Report

PASADENA INDEPENDENT SCHOOL DISTRICT

CALL-IN ACCIDENT REPORT

DATE OF ACCIDENT:__________________________________________________

TIME: ______________ SOCIAL SECURITY NO: ___________________________

NAME: _______________________________________________________________

SCHOOL’S NAME AND LOCATION IN BUILDING: _______________________

TIME EMPLOYEE BEGAN WORK (A.M. / PM.): __________________________

DOES EMPLOYEE SPEAK ENGLISH? YES_____ /NO _____Language________

MARITAL STATUS: married___widowed___separated___single___divorced_____

NUMBER OF DEPENDENT CHILDREN: ___________

OCCUPATION: ________________________________________________________

IMMEDIATE SUPERVISOR: ____________________________________________

INJURY / ILLNESS (TYPE): _____________________________________________

BRIEF DESCRIPTION OF ACCIDENT: ___________________________________

_______________________________________________________________________

WITNESS: ____________________________________________________________

WERE SAFEGUARDS OR SAFETY EQUIPMENT PROVIDED? _____________

WERE THEY USED?____________________________________________________

DOCTOR’S NAME AND MAILING ADDRESS: ____________________________

_______________________________________________________________________

*ASK DOCTOR’S OFFICE TO FAX US A WORK STATUS TO (713) 740-7832 DID EMPLOYEE CHOOSE DOCTOR? ___________________________________

HAS EMPLOYEE GONE TO THE DOCTOR? YES______NO________________

IS EMPLOYEE SCHEDULED TO GO TO DR. ? YES______NO______________

DAYS MISSED / OR ANTICIPATED: _____________________________________

PERSON CALLING IN REPORT: ________________________________________

CALL RECEIVED BY: ______________________ DATE RECEIVED: __________

TIME RECEIVED: ______________________________________________________

REVISED 07/31/04