Last modified: março 25, 2025

Policy 5120 5120 P1 Employee Accident/Injury Reporting

Download Policy 5120 5120 Employee Accident/Injury Reporting

Employee Accident/Injury Reporting Procedure

IN THE EVENT OF A LIFE OR LIMB THREATENING INJURY, CALL 911

For Non-Life Threatening Injuries:

Report any accident or injury to your supervisor.
Call Company Nurse at 1-888-375-0279.
- In order for Workers’ Compensation to be considered, you must call Company Nurse for instructions. The District has contracted with Company Nurse to provide a triage service. To receive Workers’ Compensation benefits, this step is required.
- A registered nurse from the triage service will help assess the injury and refer you to the most appropriate level of care – such as an ER, clinic, or provide first aid guidelines.
- Follow the instructions of Company Nurse, including where to seek medical attention. If referred to urgent care, go to one of the facilities listed below:
OREM WORKMED 830 North 980 West Orem, Utah 84057 Phone: 801-724-4000 Hours: M-F, 8:00 am – 5:00 pm

CONCENTRA OREM 601 North 1200 West Orem, Utah 84057 Phone: 801-224-4211 Hours: M-F, 8:00 am – 5:00 pm

SPRINGVILLE WORKMED 385 South 400 East Springville, Utah 84663 Phone: 801-491-6400 Hours: M-F, 8:00 am – 5:00 pm

Seeking treatment at a regular physician will not be covered unless referred by Company Nurse. You may change doctors once after initial treatment at a designated facility.
Submit a completed Employee’s Statement Regarding Accident (5120 F1) to the HR/Benefits Office and an Employee Accident Information Form (5120 F4) to the designated staff member. These steps are required to receive benefits.

Workers’ Compensation Benefits

When an employee is kept away from work by an on-the-job injury, workers’ compensation benefits and sick leave benefits will be coordinated as follows:

Except in cases of extended disability, workers’ compensation will not provide benefits during the first three calendar days following an on-the-job injury. If any of these three days are contract working days, the employee may use accrued sick leave and receive full pay for these days. Classified and secretarial hourly employees who normally work four or more hours per day will be paid their daily rate for the hours normally worked for any work days associated with the three-day waiting period.
Payments under workers’ compensation, beginning with the fourth day after the injury, may be somewhat less than the employee’s regular salary. If the employee wishes to do so, the employee may use accrued sick leaved to make up the difference between workers’ compensation payments and regular salary. The time charged to the employee’s sick leave account will be prorated so that, for example only a quarter of the day will be charged to sick leave, if that is all it takes to bring the total compensation up to the level of the employee’s regular salary.
Recuperation from workers’ compensation injuries must be in total compliance with the doctor’s prescribed plan. Employees should not do anything that could worsen or delay the healing process. Any variation from rest and limited activity must be prescribed by a doctor and have prior approval by the District Human Resource office before engaging in travel.

Responsabilidades

1. Employees are responsible to:

Follow safe work practices.
Report any conditions that they consider unsafe to their supervisor or the HR/Benefits Office.
Promptly report occupational accidents to their supervisor.
Call Company Nurse to report injury and receive instructions.
Report any conditions that they consider unsafe to their supervisor or the HR/Benefits Office. Promptly report occupational accidents to their supervisor. Call Company Nurse to report injury and receive instructions. Report occupational accidents to HR/Benefits Office as soon as possible but not later than five workdays following the accident, by completing the Employee’s Statement Regarding Accident (5120 F1).
Complete the Employee Accident Information Form (5120 F4) and return it to the designated staff member. (Each dept./location has a designated staff member to enter employee accident information on the USBAWC website – online form 122.)
Failure to report any occupational accident may result in the denial of benefits under worker compensation laws. Submit a copy of all Doctor’s notes to the Human Resource Benefits Office.

2. The employee’s immediate supervisor is responsible to:

Obtain prompt medical treatment for the injured employee and securing the accident scene as appropriate.
Keep all injury information confidential.
Complete Supervisor’s Accident Investigation Report (5120 F2) and return it to HR/Benefits Office as soon as possible.
Complete a Witness Statement Form (5120 F3) (or have any witnesses complete a Witness Statement Form) and return it to HR/Benefits Office as soon as possible.
Report the incident to HR/Benefits Office, in the event the injured employee is unable to do so.

3. The HR/Benefits Office is responsible to:

Coordinate with the supervisor in providing temporary, light duty, or alternative work assignments to injured employees as appropriate.
Fax or email Employee’s Statement (5120 F1), Supervisor’s Accident Investigation Report (5120 F2), and any Witness Statement forms (5120 F3) to Utah School Boards Risk Management Mutual Insurance Association.
Assure that new employees are aware of and understand the policy through the new hire orientation process.
Coordinate and follow up on claims as necessary.

Aprovado pelo Conselho de Educação

Setembro de 2011

Revised: July 2014, July 2017, January 2019