Instructions for Accident Report

1. The INJURED PARTY completes Section 1:

• after completing it, sign and date Section 1,
• give Accident Report to supervisor.

2. The SUPERVISOR to whom the injury was reported completes Section 2:

• after completing it, sign and date Section 2,
• make a photocopy of report for the injured party's personal records,
• give original Accident Report to an authorized department personnel (personnel officer, administrator, payroll coordinator, etc.).

3. The DEPARTMENT PERSONNEL completes Section 3:

• after completing it, sign and date Section 3,
• make sure Sections 1 & 2 are complete and signed,
• make two photocopies: keep one copy for department files, send second copy to:

Lenny Solomon
Chair of Safety Committee
The Link (Mallinckrodt), Rm. 264

• immediately send the original completed Accident Report to:

  Disability Claims Unit
  664 Holyoke Center

Questions? Please telephone the Disability Claims Unit at 495-9054.

First Aid Treatment involves:

• antiseptic, application of, on a first visit to a doctor or nurse
• bandaging on any visit to a doctor or nurse
• burns of first degree
• compresses, hot or cold, on a first visit to a doctor or nurse
• elastic bandage, use of, on first visit to a doctor or nurse only
• foreign body, not embedded, irrigation of eye for removal
• foreign body, removal from wound by tweezers or other simple techniques
• non-perscription medications used
• observation of injury on second or subsequent visit
• ointments applied to abrasions to prevent drying or cracking
• Tetanus shot, initial or booster alone
• hospitalization for observation
• x-ray which is negative

Medical Treatment involves:

• antiseptic applied on a second or subsequent visit to a doctor or nurse
• burns of a second or third degree
• butterfly sutures
• compresses, hot or cold, on second or subsequent visit to a doctor or nurse
• cutting away dead skin (surgical debridement)
• foreign bodies, removal if embedded in eye
• foreign body, if removal from wound required a physician because of depth of embedment, size or shape of object(s) or location of wound
• infection, treatment for
• prescription medications used
• soaking, hot or cold, on second or subsequent visit
• sutures (stitches)
• whirlpool treatment
• x-ray which is positive