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EMPLOYEE INCIDENT & ILLNESS REPORT FORM# 3012

RHA Unit Name:___________________________________________

Employee’s Regular Work Site:__________________________________

A. EMPLOYEE INFORMATION (Section A to be completed by employee) 1. Last Name:______________________ _____

First Name:______________________________________

2. Home Address:__________________________________ ______________________ ______ ___________ STREET, PO BOX

CITY

STATE

3. Social Security Number: ______ _____ ______ Phone: (______) _________________ Email: ________________________________ 4. D.O.B.: ___/___/___

Sex:

5. # hours worked per day:_______ Usual shift hours: _____ to ______

Marital Status:___________________________________

Hire Date: ___/___/___ Job Title:_______________________ per week:_________

# days per week:____________

Time began work: ____:____

6. Date & Time of Accident: ___/___/___ ____:____ DATE

ZIP

TIME

7. Speciﬁc location in home/facility where injury occurred: _________________________________________ (e.g. kitchen, bathroom, backyard) a. On company premises? Yes No b. Unit/home where incident occurred: ________________________________________________________ c. If not on company premises, where did accident occur? ________________________________________ i. Please list address where incident occurred: ________________________________________________ ________________________________________________________________________________________________

FACTS OF INJURY 8. Explain in your own words what you were doing just prior to the accident._________________________

___________________________________________________________________________________ ___________________________________________________________________________________ 9. What happened? Describe how the injury or illness occurred.___________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ 10. What factors do you believe contributed to your accident (e.g. faulty equipment, wet surface, lifting, etc.)?

___________________________________________________________________________________ ___________________________________________________________________________________

Last Modiﬁed: 1/29/25

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Form# 3012

11. Were there any witnesses to your injury?

Yes No If yes, provide ﬁrst & last name(s) below: ___________________________________________ ___________________________________________________ ___________________________________________

___________________________________________________

12. Have you received safety training related to this injury?

Yes

13. Were safety devices available (i.e. rubber gloves, Hoyer lift, gait belt, lift belt, etc.)?

Yes

If yes, what device were you using at the time?__________________________________________________

NATURE OF INJURY 14. Nature and extent of injury or illness (e.g. laceration of left thumb, strain lower back, forehead contusion, bruised left leg, human bite to right shoulder): _________________________________________________________________________ __________________________________________________________________________________________________________

15. What is your dominant hand?

Left

Right

16. Was this injury client related?

Yes

If yes, record client initials: ____ ____ then mark and complete A, B or C below. A. Injury was related to client behavior (DO NOT USE CLIENT NAME, ONLY INITIALS.) 1. Are you familiar with the client’s Individual Support Plan or Treatment Plan?

YES

2. Does the client have a Behavior Support Plan (BSP) or Crisis Plan?

UNKNOWN

3. Did you receive training in verbal de-escalation?

YES

3a. If yes, did verbal de-escalation help in this situation? 4. Have you been trained in physical intervention procedures? 4a. Did you use a physical intervention procedure?

YES

YES YES

YES

4b. If yes, did injury occur before or during intervention?

Before

During

5. Are you aware of any signiﬁcant changes related to the individual such as medication changes, family changes, employment changes, emotional stressors, medical conditions, new admission? 6. Do you work with this individual on a routine basis?

YES

B. Injury was related to lifting a client. 1. Have you received training on proper lifting techniques?

Yes

2. What is the client’s lift/transfer method identiﬁed in their PCP/ISP/Service Plan?___________________ 3. What type of lift were you administering? (e.g. pivot, two/three-man lift, etc.)______________________ 4. What type of lifting aid were you using? (e.g. lifting belt, gait belt, Hoyer lift)_______________________

C. Injury was client related for other than behavior or lift. Last Modiﬁed: 1/29/25

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Form# 3012

1. What type of client related injury occurred? __________________________________________________ 2. Is there a training mechanism that could have prevented this injury?

YES

If yes, explain ___________________________________________________________________________ _______________________________________________________________________________________

Slip, trip, or fall incident. 1. What shoes were you wearing?________________________________ 2. Was the slip, trip, or fall related to a client? If yes, how?______________________________________ ______________________________________________________________________________________ 3. What was the surface/condition of the surface you slipped, tripped, or fell on? ___________________ _______________________________________________________________________________________ 17. List any prior problems or injuries you’ve experienced to the same body location: ____________________

___________________________________________________________________________________ 18. In your opinion, what could have prevented this accident? ___________________________________________

___________________________________________________________________________________ The information provided is completed to the best of my knowledge. I understand that medical treatment must be rendered by an RHA appointed Company physician/facility. Only if I need immediate emergency medical treatment may I utilize another medical provider or hospital emergency room. Follow up care must be provided by the Company physician with direction of my facility nursing department, HR department or facility designee. Employee Signature: ______________________________________________

Date:______________________

All incidents are to be reported promptly to your immediate supervisor. Failure to report this claim and participate in the accident investigation could delay workers’ compensation beneﬁts. Date Reported to Supervisor: ______________ Name of Supervisor: ___________________________________________________ NOTE: If the injured employee is not available, the employee information (where known) should be completed promptly by supervisor with follow up ASAP to get an employee statement completed. Person Completing Report for Employee Signature:___________________________________________

Date:________________

Print Name:___________________________________________ Last Modiﬁed: 1/29/25

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Form# 3012

REPORT SUBMISSION Please scan to yourself, then email at least the 1st three (3) pages before the end of shift to: ROBERT PHILLIPS ROBERT.PHILLIPS@RHANET.ORG BH NORTH CAROLINA, GEORGIA, TENNESSEE MEGHAN WALDROP MWALDROP@RHANET.ORG IDD NORTH CAROLINA, NEW JERSEY, PENNSYLVANIA CC: CARLA BROWN CBROWN@RHANET.ORG ALL STATES

Last Modiﬁed: 1/29/25

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Form# 3012

EMPLOYEE INCIDENT & ILLNESS REPORT B. SUPERVISOR’S ACCIDENT INVESTIGATION REPORT (THIS SHOULD BE COMPLETED AFTER YOU HAVE CONDUCTED YOUR ACCIDENT INVESTIGATION PROCESS)

1. When were you ﬁrst informed of the incident / accident/ exposure? ___________ ___:____ DATE

TIME

By Whom: _____________________________________________________________________ 2. Describe your account or impression of how the accident occurred:______________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ 3. Was this injury/illness an unsafe ACT or CONDITION?

ACT

CONDITION

4. Did this accident result from a violation of safety rules/ policies?

Yes

5. How could this accident have been prevented? _________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ 6. What do you believe you can do to help prevent future accidents of this kind? ______________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ 7. Who is investigating this accident? _____________________________________________________________ 8. Were the six key investigative questions used to assist in the investigation (who, what, where, when, why, how)?

Yes

9. Did you obtain statements from witnesses?

Yes

If yes, please attach.

10. Do you have concerns about any statements made by the employee or any witness to this incident? Yes

If yes, please provide rationale. ______________________________________________

_________________________________________________________________________________________________ _________________________________________________________________________________________________ *If the employee injury was a slip, trip, fall incident or struck by client incident, complete applicable section on page 6.* Supervisor’s Name (Please print):__________________________________________ Date: _________________ Supervisor’s Signature:__________________________________________________________________________

Last Modiﬁed: 1/29/25

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Form# 3012

The purpose of this investigation is to determine the root cause and ﬁnd ways to prevent this and similar incidents.

SLIP, TRIP, FALL INCIDENT

1. Did the person receiving services cause or contribute to the employee’s slip, trip, fall incident? YES

NO If yes,how?__________________________________________________________________

_________________________________________________________________________________________________ _________________________________________________________________________________________________ 2. Verify what footwear the employee was wearing? ______________________________________________ 3. If incident occurred in the bathroom, are proper mats on the ﬂoor? YES NO N/a 4. Did you go to location of the incident during this investigation? YES NO 5. What was the physical condition of the area when the accident occurred (e.g. wet, muddy; debris in the way, area was clear)?__________________________________________________________________________ 6. Did an object contribute to the incident (e.g. electrical cord, broken chair, window drapes)? YES NO If yes, what was the object? _________________________________________________ 7. Did the incident occur on an established walkway (driveway, sidewalk) or did the employee take a “short cut” or veer off the established walkway or path? _____________________________________________ _________________________________________________________________________________________________ 8. Is the walking surface upon which the employee slipped/ tripped in good repair? YES NO 9. Was the employee distracted when this incident occurred (e.g. looking at handheld device, talking to someone, trying to multitask)? YES NO If yes, how? ________________________________________ _________________________________________________________________________________________________

STRUCK BY CLIENT INCIDENT

1. Is the client a new admission (6 months or less) to the facility? YES NO 2. Does the employee work with this individual on a routine basis? YES NO 3. Does the client have a BSP/Crisis Plan? YES NO a. If yes, Did the employee follow the client’s Behavior Support Plan (BSP)/Crisis Plan in this situation? YES NO 4. Employee’s most recent ProAct/Safety Care training date: ___/___/___ 5. Was the behavior exhibited a known behavior by the client? YES NO 6. Are you aware of any signiﬁcant changes related to the individual such as medication changes, family changes, employment changes, emotional stressors, medical conditions, new admission? YES

7. Upon review, do you feel the communication from staff was appropriate? (i.e. Verbal interaction, body language, gestures) YES NO 8. Based on the above responses, what corrective measures are being taken? (Attach additional pages if needed)____________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________

Last Modiﬁed: 1/29/25

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Form# 3012

EMPLOYEE INCIDENT & ILLNESS REPORT C. NURSING EVALUATION (To be completed by RHA Nurse) 1. Date/Time employee was evaluated by Nurse: _____________ _____:____ DATE

TIME

2. Date/Time the nurse was ﬁrst made aware of the injury: _____________ ____:_____ DATE

TIME

3. Type of Injury / Chief complaint: _______________________________________________________________________________________________ Treatment Rendered: _________________________________________________________________________ Recommendation: ___________________________________________________________________________ 4. Was medical treatment offered to the injured employee? Was this

your recommendation or

Yes

employee request?

Did the employee go to the doctor/ clinic?

Yes

5. Did you send Medical Authorization/ Physical Capacities Treatment Form #3096? 6. Did the authorized physician place the injured employee out of work?

Yes

If yes, what is the projected length of lost time? _________________________________________________ NOTE: If more than 3 days, this may be an FMLA qualifying event. Please contact the Corporate Safety/Workers Compensation Analyst ASAP. 7. Nurses narrative:______________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ 8. If the employee died, when/where did the death occur: ___________________________________________ Nurse’s Name (Please print):__________________________________________

Date: __________________

Nurse’s Signature:_______________________________________________________________________________

________________________________________________ As you evaluate this report, please ensure that all items are addressed with explicit legible information and that witness statements, medical statements, and supporting documentation are attached and validate the claim.

Please complete the Administrator’s Accident Investigation Feedback Form attached to this form. Administrator’s Signature________________________________________________

Date: _______________

Administrator’s Comments:_______________________________________________________________________ _________________________________________________________________________________________________ **Scan and email to the Corporate Safety Department.

Last Modiﬁed: 1/29/25

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Form# 3012

EMPLOYEE INCIDENT & ILLNESS REPORT

ADMINISTRATOR’S ACCIDENT INVESTIGATION FEEDBACK FORM

Category Ratings: 3= Good 2= Satisfactory 1= Needs Improvement Rate performance in sections A-D then calculate Overall Rating at bottom of page Investigation conducted by: ____________________________ Manager: _________________________ Injured Employee: _____________________________________ Incident Date: ______________ Report completed within Same day 2-5 days Greater than 5 days If the report was not completed within the same day, why not? __________________________ _____________________________________________________________________________________

A. DESCRIPTION OF INCIDENT

Were detailed speciﬁcs regarding the accident description included? (i.e. size/weight of object, part of body injured, equipment, tools, environment) Comments: __________________________________________________________________________________ _____________________________________________________________________________________________

B. PRIMARY CAUSES AND CONTRIBUTING FACTORS IDENTIFIED

Were multiple causes identiﬁed? Was the root cause identiﬁed? Comments: _____________________________________________________________________________________ _____________________________________________________________________________________

C. APPROPRIATE CORRECTIVE ACTIONS SUGGESTED :

Were appropriate corrective actions identiﬁed for each cause? Were target dates and a person responsible assigned for each corrective action? Comments:

Were appropriate follow up actions identiﬁed for each corrective action? Were target dates and a person responsible assigned for each follow up action? Comments:

__________________________________________________________________________________ __________________________________________________________________________________

OVERALL RATING:____________ (A+B+C+D)/4

Last Modiﬁed: 1/29/25

Completed by: ____________________________

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Form# 3012