Instructions for Completing Form IA-1 (First Report of Injury)

SHADED FIELDS: Do not write in gray areas. These are for the claims administrator to fill out.

WHITE FIELDS: Fill out as completely as possible as noted later in these instructions.

DATES: Enter all dates in MM/DD/YY format. (Example: 12/25/01)

1. CASE LOG NUMBER FROM OSHA 300 FORM (IF RECORDABLE)

If the injury is recordable according to OSHA, then enter the case number from Column A of the OSHA 300 Log. Otherwise, leave blank.

2. LOCATION NUMBER

Enter the work location where the incident occurred. If the incident occurred during work-related activities at a site that is not NK Health’s, then leave this field blank. The valid choices are:

001 = District Office

002 = Campbell County Health Center

003 = Kenton County Health Center

004 = Grant County Health Center

005 = Intentionally left blank

006 = Boone County Health Center

3. EMPLOYERS LOCATION ADDRESS (IF DIFFERENT)

If the incident occurred at any address other than the District Office, enter the address of the NKY Health worksite where the incident occurred. Be sure to include the zip code. If the incident occurred offsite, then enter the address of the employee’s workstation.

4. SELF INSURANCE

Do not check this box. Leave it blank.

5. NAME (LAST, FIRST, MIDDLE)

Enter the injured/ill employee’s last name, then first name, then middle initial.

6. ADDRESS (INCL ZIP)

Enter the injured/ill employee’s home address. Be sure to include the zip code.

7. PHONE

Enter the injured/ill employee’s home phone number. Be sure to include the area code.

8. WAGE RATE

Enter the injured/ill employee’s pay rate, enter that information, put an X on “Other,” and write “hourly” next to “Other.”

9. DATE OF BIRTH

Enter the injured/ill employee’s date of birth in mm/dd/yy format.

10. SEX

Put an X on Male, Female, or Unknown.

11. NO. OF DEPENDENTS

Leave blank.

12. SOCIAL SECURITY NUMBER

Enter the injured/ill employee’s social security number.

13. MARITAL STATUS

Put an X on Unmarried, Married, Separated or Unknown.

14. # DAYS WORKED/WEEK

Enter the number of days the injured/ill employee works in a week.

15. # HOURS WORKED/DAY

Enter the number of hours the injured/ill employee works in normal workday.

16. DATE HIRED

Enter the date the injured/ill employee started with NKY Health in mm/dd/yy format.

17. OCCUPATION/JOB TITLE:

Enter the title of the injured/ill employee at the time of the incident. (Example: Public Health Nurse)

18. EMPLOYMENT STATUS:

Indicate the injured/ill employee's work status. The valid choices are:

• Full- Time

• Part-Time

19. FULL PAY FOR DAY OF INJURY?

Leave blank.

20. DID SALARY CONTINUE?

Leave blank.

21. TIME EMPLOYEE BEGAN WORK

Enter the time the injured/ill employee began work on the day of the incident and put an X next to a.m. or p.m.

22. DATE OF INJURY/ILLNESS

Enter the date of the incident in mm/dd/yy format.

23. TIME OCCURRED

Enter the time the injury/illness occurred in mm/dd/yy format.

24. LAST WORK DATE

Enter the date that the injured/ill employee last worked in mm/dd/yy format.

25. DATE EMPLOYER NOTIFIED

Enter the date the injured/ill employee notified his/her supervisor of the injury/illness in mm/dd/yy format.

26. DATE DISABILITY BEGAN

Enter the date of the first day the injured/ill employee lost time from work due to the injury or illness in mm/dd/yy format.

27. EMPLOYER CONTACT NAME/PHONE NUMBER

Enter the name of the individual at the employer's premises to be contacted for additional information. Enter the contact information for the head of Human Resources (currently Karen Domaschko).

28. TYPE OF INJURY/JLLNESS

Briefly describe the nature of the injury or illness, (Example: lacerations to the forearm).

29. PART OF BODY AFFECTED

Indicate the part of body affected by the injury/illness, (Example: right forearm, lower back).

30. DID INJURY/ILLNESS EXPOSURE OCCUR ON EMPLOYER’S PREMESIS?

Select “yes” if it occurred at any of the NKY Health’s facilities; Select “no” if it occurred anywhere other than one of the NKY Health’s facilities.

31. DEPARTMENT OR LOCATION WHERE ACCIDENT OR ILLNESS EXPOSURE OCCURRED

(Example: Client’s home at 123 Main Street, Covington, KY 41011)

If the accident or illness exposure did not occur on the employer’s premises, enter the address or the location. Be specific.

32. ALL EQUIPMENT, MATERIAL OR CHEMICALS EMPLOYEE WAS USING WHEN ACCIDENT OR ILLNESS EXPOSURE OCCURRED

List all of the equipment, materials and/or chemicals the employee was using, applying, handling, or operating when the injury or illness occurred. Be specific. (Example: syringe)

Enter "N/A" for not applicable if no equipment, materials, or chemicals were being used. NOTE: The items listed do not have to be directly involved in the employee's injury or illness. (Example: clipboard.)

33. SPECIFIC ACTIVITY THE EMPLOYEE WAS ENGAGED IN WHEN THE ACCIDENT OR ILLNESS EXPOSURE OCCURRED

Describe the specific activity the employee was engaged in when the accident or illness exposure occurred.

(Example: Administering vaccination to client.)

34. WORK PROCESS THE EMPLOYEE WAS ENGAGED IN WHEN ACCIDENT OR ILLNESS EXPOSURE OCCURRED

Describe the work process the employee was engaged in when the accident or illness exposure occurred. (Example:  Building Maintenance).

Enter "N/A" for not applicable if employee was not engaged in a work process (Example: walking along a hallway.)

35. HOW INJURY OR ILLNESS/ABNORMAL HEALTH CONDITION OCCURRED. DESCRIBE THE SEQUENCE OF EVENTS AND INCLUDE ANY OBJECTS OR SUBSTANCES THAT DIRECTLY INJURED THE EMPLOYEE OR MADE THE EMPLOYEE ILL

Describe how the injury or illness/abnormal health condition occurred. Include the sequence of events and name any objects or substance that directly injured the employee or made the employee ill. (Example: Worker stepped to the edge of the scaffolding to inspect work. lost balance and fell six feet to the floor. The worker's right wrist was broken in the fall.)

36. DATE RETURN(ED) TO WORK

Enter the date on which the injured/ill employee returned to work or is expected to return to work in mm/dd/yy format.

37. IF FATAL, GIVE DATE OF DEATH

Enter the date the injured/ill employee died from the incident in mm/dd/yy format.

38. WERE SAFEGUARDS OR SAFETY EQUIPMENT PROVIDED?

Select either Yes or No.

39. WERE THEY USED?

Select either Yes or No.

40. PHYSICIAN/HEALTH CARE PROVIDER (NAME & ADDRESS)

Enter the name and address of the provider the employee will see as a result of this injury/illness. Be sure to check with Bluegrass Health Network to ensure that this provider is a gatekeeper.

41. HOSPITAL (NAME & ADDRESS)

If the injured/ill employee went to the hospital, enter the name and address of the hospital.

42. WITNESS TO ACCIDENT (NAME & PHONE #)

Enter the first and last names of anyone who witnessed the incident. For each person listed, enter her/his daytime phone number. Be sure to include the area code.

43. DATE ADMINISTRATOR NOTIFIED

Enter the date and method by which you notified the head of Human Resources of the incident.

44. DATE PREPARED

Enter the date you are completing this form in mm/dd/yy format.

45. PREPARER’S NAME & TITLE

Enter your name and title. (You should be the injured/ill employee’s supervisor.)

46. PREPARER’S PHONE NUMBER

Enter your daytime phone number. Be sure to include the area code.

47. INITIAL TREATMENT

Put an X on the FIRST type of treatment the injured/ill employee received. (Example: a band-aid would be “minor by employer.”)

48. EMPLOYEE SIGNATURE (ON BACK)

Have the injured/ill employee sign if he or she is able. Otherwise, print the completed form, write his or her name followed by “by,” followed by your signature (Example:  Fname Lname by Fname2 Lname2) then have her/him sign as soon as s/he is able and forward the signed form to the head of Human Resources.