Employee/Payroll Agency Injury/Illness Form

Employee/Payroll Agency

Injury/Illness Form

Accident Reporting

All accidents shall be investigated as soon as possible by the injured worker’s immediate supervisor or department manager.

The accident form shall be completed, as soon as possible, but under no circumstances more than 24 hours following an accident.

If the injury/illness involves the hospitalization of an employee, ESPN Security (860-766-2214) shall be notified immediately (within 4 hours of the occurrence).

This report is being completed at the request of the Legal Department in anticipation of claims or litigation. This report and all information contained in it is confidential and subject to the attorney client and/or work privilege(s).

This report does NOT apply to employee's that work at a TWDC facility.

Please utilize Riskonnect linked here: https://twdc.sharepoint.com/sites/CORP-ERM

For any questions related to accident reporting, please visit:

https://disney.service-now.com/mydisneytoday?id=mydisneytoday_content_page&page_id=accidentreporting

Date of Event*

Month of Event*

Select or enter value

Time Emp Started Work*

Example - 3:00 p.m.

Time of Incident*

Standard Time (ex. 3:00 p.m.)

Name of Worker*

Provide Employee's Full Name.

For TWDC Employees, provide it as it is listed in Workday.

Job Title*

Worker Type*

Select or enter value

Perner Number*

Payroll Agency*

A payroll agency worker is a contractor hired by a payroll agency but works under the direction of TWDC management.

Vendors work independently of TWDC and are not directed by TWDC management. If the worker is a vendor, fill out the spectator/guest/vendor accident form.

Spectator/Guest/Vendor Accident Form

https://app.smartsheet.com/sheets/2qgG34VpxH7hWrCxPvPmH9Hp99XvX5RQJjjvPCQ1?view=grid

Select or enter value

Name and Phone Number of Payroll Agency*

Affected Worker's Email*

Telephone Number of Worker*

Phone

Home State/Territory of Worker*

Select or enter value

Worker’s Supervisor or Onsite Ops Manager*

Provide: Name, Job Title, Phone Number, E-Mail Address

Did the Incident Occur During a ESPN Remote Event?

Select or enter value

Type of Remote Production*

Select or enter value

If Other, Please Specify

Location of Accident (Street, Venue, City, State)*

What Was Worker Doing Before Incident?*

Example - Worker was pulling cable

Accident Description*

Please be specifc (think who, what, when, where, why)

Cause*

Injury/Illness Type*

Select or enter value

Was Medical Care Provided?*

Select or enter value

Was Worker Admitted to Hospital?*

If the injury/illness involves the hospitalization of an employee, ESPN Security (860-766-2214) shall be notified immediately (within 4 hours of the occurrence).

Select or enter value

Where did Worker Receive Treatment?*

Example - Saint Mary's, 1 Main Street, Springfield, MA

Did Accident Result in a Fatality?*

If the accident resulted in a fatality, call ESPN security immediately at 860-766-2486. Fatalities must be reported to OSHA within 8 hours of the incident.

Select

What Treatment did the Worker Receive?*

No treatment received, first aid treatment, treatment beyond first aid - be specific!

What Steps Were Taken to Mitigate the Hazard?*

Example - Hazard was removed, employee received training, engineering controls were established, nonapplicable.

Name, Title, E-mail, and Phone Number of Reporter?*

Example - Joe Smith, Ops Manager, Joe.Smith@espn.com, 555-555-5555

File Upload

Update photos if applicable

Drag and drop files here or

Date Reported to Employer*

Please Check This Box Prior to Submitting*

**This document should not be shared - please do not forward**

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