FCUSD Employee Accident/Incident Report

 
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  FCUSD Employee Accident/Incident Report 
Please complete this form anytime you have experienced an accident or other employee-related incident in the workplace. Folsom Cordova's Human Resources office will forward to the appropriate designee, who may determine that additional investigation is needed and may contact you for follow up. If you have additional questions, please contact Human Resources at (916) 294-9000 ext. 104410.

In addition to this form, all incidents and accidents must also be reported to immediate supervisor.

 
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Please also indicate your workday Start and End times:
 
   
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(PO Box or Street #, City, State, Zip)
 
   
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If yes, your Supervisor will notify your district office to secure a referral slip to a SIG Medical Network Provider. If medical aid is not required at this time, your Supervisor will retain a copy of the incident report and forward a copy to the district office. If medical attention is not needed for this incident now but is necessary at a later date, you understand that you MUST contact your site supervisor and the District Office Claims Coordinator PRIOR TO seeking or obtaining treatment. Failure to report occupational injuries in a timely manner and/or failure to comply with the District's policies for medical treatment of occupational injuries could result in disciplinary action. It may also result in a delay of any possible Workers' Compensation benefits while the District and the insurance carrier investigate your claim.
 
If yes, your Supervisor will notify your district office to secure a referral slip to a SIG Medical Network Provider. If medical aid is not required at this time, your Supervisor will retain a copy of the incident report and forward a copy to the district office. If medical attention is not needed for this incident now but is necessary at a later date, you understand that you MUST contact your site supervisor and the District Office Claims Coordinator PRIOR TO seeking or obtaining treatment. Failure to report occupational injuries in a timely manner and/or failure to comply with the District's policies for medical treatment of occupational injuries could result in disciplinary action. It may also result in a delay of any possible Workers' Compensation benefits while the District and the insurance carrier investigate your claim.
   
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Please type your name here to submit your report.
 
   
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  Select Date
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