Incident Reporting Forms

Employee Incident Reporting

STEP1: Employee Incident Report Form - Employee Statement and Certification

Immediately after receiving first aid or emergency care needed, employees who are injured or who become ill as a result of a work activity must complete and submit this form.

When the injury/illness renders an employee unable to complete the form please contact the head of Human Resources for further instruction.

Please consult the head of Human Resources with questions about this form.

STEP 2: Employee Incident Report Form -Supervisor Statement and Certification

Immediately upon receipt of the Employee Incident Report - Employee Statement and Certification form that the employee submits, the supervisor reviews the details and then completes and submits the Employee Incident Report - Supervisor Statement and Certification form.

Please consult the head of Human Resources with questions about this form.

STEP 3: First Report Form IA-1 Workers Compensation First Report of Injury or Illness

Immediately after submitting the Employee Incident Report - Supervisor Statement and Certification form, the supervisor completes and routes this form to report injuries/illnesses that an NKY Health employee sustains as a result of something that happened at work to the Workers Compensation carrier.

The supervisor uses the information reported in the Employee Incident Report - Employee Statement and Certification form that the employee submitted (and corrects any accuracies as s/he completes the report.)

During normal business operations supervisors, initiate the form USING THE "WORKERS COMPENSATION" WORKFLOW IN ADOBESIGN. (Adobesign will guide them through the fields.) When the workflow is unavailable due to a technology failure, then supervisors must complete the form below by filling it in electronically, then print, sign and ensure the employee signs the second page. Please use the form below ONLY when AdobeSIgn is unavailable.)

Please see the Instructions for Completing Form IA-1 in the "Incident Management" section of NKY Health's Safety Manual for specific instructions. AdobeSign will route the form internally but the supervisor must print it and fax it to the Workers' Compensation Carrier as soon as it is signed. (In the event of a technology failure causing the form below to be used, the supervisor must also route the form to Human Resources and to her/his Division Director.)

Please consult the head of Human Resources with questions about completing this form.

First Report Form IA 1-1-2021.pdf

Visitor Incident Reporting

STEP 1: Visitor Incident Report Form - Employee Statement and Certification

Employee's use this form to report safety-related incidents involving visitors when an incident occurs at an NKY Health site. (Visitors include clients, staff from other agencies working at NKY Health, guests at meetings, etc.)

Please consult the Deputy Director of Health with questions about this form.

STEP 2: Visitor Incident Report Form - Manager Statement and Certification

Upon receipt of the Visitor Incident Report - Employee Statement and Certification form that employees submits, the manager responsible for the site where the incident occurred reviews the details and then completes and submits the Visitor Incident Report - Manager Statement and Certification form.