EMPLOYEE ACCIDENT REPORT INDIANA WORKER’S COMPENSATION **** FOLLOW-UP REPORT **** (This report is to be completed by Principal/Supervisor the day AFTER the accident.)
Employee Name: Date of Injury:
School:
Initial Treatment at time of Accident:
NO Medical Treatment Minor Treatment by Employer Treated at Clinic or by Doctor Treated at Hospital Emergency Room Hospitalized
Did employee leave work? If yes, how long was employee absent?
YES
NO Remainder of day only Following day Anticipate extended absence
What is the status of the employee’s health the day after accident (bruising, lacerations, no problems, etc.)?
Date
______________________________ Signature of Principal/Supervisor After completion, send this form to Jenny Sanders, Administration Center, School City of Mishawaka
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