C3 Supervisor's First Report of Injury

First Priority: Health & Safety - For Serious Injuries Dial 911 Immediately!

1. Immediately report all work related injuries to Laura Wood (513) 466-0455.

2. Following the notice of work-related injury please complete all necessary paperwork as follows:

a. Employee Injury Report or Refusal Of Medical Care Form

b. Medical Treatment Authorization Form (if applicable)

c. Supervisor First Report of Injury.

3. Assist the injured employee by locating the nearest Occupational Medical facility. The injured worker MUST be sent to the medical facility with a completed medical authorization form.

4. Final Step - Please upload Employee Injury Report or Refusal of Medical Care and any other relevant documents when submitting this form.

Supervisor's - please complete this form with as much detail as possible.

Thank you!

Festival Name:

Department:

Today's Date:

Employee Name:

Employee DOB:

Phone Number:

Marital Status:

Date of Hire:

Job Title:

Job Duties:

Direct Supervisor Name & Phone Number

Sex:

Date of Injury

Time of Injury:

Please describe body part affected (i.e. cut foot)

How did the accident occur? Describe events:

What object or substance directly harmed employee:

Location where injury took place (i.e. stage):

NAme two persons who saw the accident:

Name & Phone Number

Date & time Supervisor was notified of injury:

Days worked prior to injury:

Did you complete your shift day of injury:

Work shift start time (day of inury):

Last day scheduled to work on project:

Was the accident caused by another person? If so, whom?

What was the employee's assigned task a the time of injury?

Venue Occupancy:

Venue Lighting Conditions:

Conditions of the grounds/floors/steps:

Did shoes/clothing contribute to the accident:

Clothing:

Shoes:

Other conditions / Details regarding location:

Did you observe any usuage of drugs / alcohol:

Did you observe any of the following:

Did you observe any of the following actions:

First Aid Response Offered:

First Aid Treatment (icepack, band-aid, ect.)

Paramedics Called:

If treated offsite, transported by:

Offsite Emergency Care:

Name of Hospital / Clinic:

Address of Hospital / Clinic:

Was employee hospitalized overnight:

Was the employee off work for at least one full day after the injury? If yes, what was the last day worked:

Has the employee returned to work? Date returned?

Any other relevant details:

Reported by:

Title:

Email:

Phone Number -

Upload employee injury form or relevant documents:

Drop your files here

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