Instructions For Industrial Injuries

 

 For Every Injury that occurs at your site:

• Administrator/Principal/Supervisor must complete the Supervisor's Incident Report with the employee

• Fill out the form completely, including Supervisor's signature and the date the report was made to the Supervisor

• Include the names of any witnesses.

• If the report is being made later than the date of the injury, add a statement from the employee as to why the report is being made late.

• Separate the form as follows:

  • White Copy - Human Resources/Benefits Office #13

  • Yellow Copy - Give to injured employee. Employee is to give this form to the doctor. If the employee is not going to see a doctor the employee may keep the copy.

  • Pink Copy - Human Resources/ Benefits #13.

  • Goldenrod Copy - Supervisor/Department Copy

 

For Employees that Seek Medical Treatment

for an Industrial Injury

 

 For every employee that seek medical treatment for a work related condition the Employer's Report of Industrial Injury must be completed.

• The form must be completed by the Supervisor/Principal/Administrator, NOT the employee

• All copies of the Employer's Report of Industrial Injury are to be sent to Human Resources/Benefits #13.

• If the employee thinks that they might seek medical treatment, complete the Employer's Report of Industrial Injury at the time the Supervisor's Incident Report is done.

 

Additional Information

 

Preferred Treatment Centers:

 

Urgent Care:

Banner Health Center (Stats Clinic)

Ahwatukee

(480) 5987500

4530 E Ray Rd

Phoenix, AZ  85044

 

Emergency Room:

Banner Health Center - Desert

(480)835-3000

1400 S Dobson Road

Mesa, AZ 85202

 

Workers Comp Carrier:

The Alliance

1-888-CLAIM-89

PO Box 33037

Phoenix, AZ  85067-3037

 

 

Please note and inform your employee that not all personal physicians will file workers compensation claims. If an employee goes to their own doctor, they could be responsible for paying the cost of the treatment.