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Supervisor's Injury/Illness Report Form

 

This report is to be completed by the Supervisor. This is a confidential report for HRD use.

Required

 

Supervisor Information

Name of Person Completing this Formrequired
First Name
Last Name

 

Employee Information

Injured Employee Namerequired
First Name
Middle (optional)
Last Name
Must contain a date in MM/DD/YYYY format
Must contain a date in MM/DD/YYYY format
0 / 5000
0 / 5000
Was personal protective equipment (PPE) required?required
0 / 1000
Was personal protective equipment (PPE) provided?required
0 / 1000
Was personal protective equipment (PPE) being used?required
0 / 1000
0 / 5000
Was safety training provided to the injured employee?required
0 / 1000
Will a service ticket be submitted for remediation of safety concern/hazard?requiredNote: If marked "Yes", include risk@vusd.org when submitting the ticket.
Note: If marked "Yes", include risk@vusd.org when submitting the ticket.
0 / 5000
Was this injury/illness a result of a Workplace Violence Incident?required
Has this type of incident occurred before at the workplace?required

 

What was the site's post-incident response?

Was emergency services and/or the YSO contacted?required
Was post-trauma counseling provided to affected staff who desired it?required
Was the district's Employee Assistance Program (EAP) provided to employee?required
Has there been follow-up with the employee(s)?required

 

 

Electronic Signaturerequired
Signature:required
First Name
Middle (optional)
Last Name
(Must contain a date in MM/DD/YYYY format)

 

 

Your Benefit Technicians

Need Help? Have Questions?

Find your designated benefits technician serving alphabetically by last name.

Marlen Allende

HRD BENEFITS TECHNICIAN
Serving Names: A-EH
Office: 559-730-7538

Jennifer Flores

HRD BENEFITS TECHNICIAN
Serving Names: EI-K
Office: 559-730-7514

Jenny Cristallo

HRD BENEFITS TECHNICIAN
Serving Names: L-RAM
Office: 559-622-3460

Jennifer Ferguson

HRD BENEFITS TECHNICIAN
Serving Names: RAN-Z
Office: 559-730-7868