Safety Reporting Forms
The following forms were approved by the Safety Committee for use as described.
- Confirmation of Transitional Duty/Return to Work Status (PDF) is completed by the employee when returning to work following an injury or illness.
- Employee Incident Report (PDF) is completed by the employee within 24 hours or as soon as possible following an injury/incident and retained by the County Officer/Department Head.
- Hepatitis B Vaccine Declination (PDF) is completed by an employee that declines the hepatitis B vaccination. (mandatory)
- Illinois Form 45: Employers First Report of Injury (PDF) is completed by the County Officer/Department Head and forwarded within 24 hours or as soon as possible to the Insurance Liaison for Claim Processing. (Required by Gallagher Bassett Services to process an employee injury claim.)
- Medical Authorization (Medical Records Release Form) (PDF) is completed by the injured party only upon request of the insurance claims adjuster.
- New Employee Safety Orientation Checklist (PDF) may be used by the County Officer, Supervisor, or Manager during orientation of a new employee.
- Non-Employee Injury Report (PDF) is completed by the injured party (other than a county employee) and filed with the County Insurance Liaison within 24 hours or as soon as possible following the injury/incident.
- Occupational Safety and Health Administration (OSHA) Form 300 - Log of Work-Related Injuries and Illnesses is a U.S. Department of Labor OSHA form to be compiled and retained by the Insurance Liaison. This form lists every work-related death, injury or illness that involves loss of consciousness, restricted work activity or job transfer, days away from work, or medical treatment beyond first aid.
- Property Damage Incident Report (PDF) is completed by the County Officer/Department Head, the Insurance Liaison or other individuals involved with property damage and filed within 24 hours or as soon as possible with the Insurance Liaison.
- Transitional Duty Guidelines Form (PDF) is completed by the employee's physician when returning to work following an injury or illness. It specifies what if any work restrictions the employee shall follow.
- Witness Statement (PDF) is completed by any/all witnesses to any type of incident within 24 hours or as soon as possible following the incident and retained by the County Officer/Department or Insurance Liaison.