HomeMy WebLinkAbout1781 RESOLUTION NO. 1781
A RESOLUTION to establish a standard format
for the reporting of injuries eo City
employees.
WHEREAS, the City has adopted a self insurance plan for
compensation of on the job injuries, and
WHEREAS, it is the intention of the City Council that all
City employees be provided the safest possible.working conditions, and
WHEREAS, as it is advisable that complete reports of all
injuries be available for review by tbe Accident Review Board and Safety
Committee, and
WHEREAS, it is necessary to have sufficient information to
properly adjudicate claims for on the job injuries.
NOW, THEREFORE, BE IT RESOLVED BY THE CITY COUNCIL OF THE CITY
OF BREMERTON that the Report of Injury to Employee (attachment "A" hereto)
will be completed and distributed as indicated whenever a City employee is
injured on the job.
PASSED BY THE CITY COUNCIL OF THE CITY OF BREMERTON, signed by the
Mayor and attested by the City Clerk in authentication of such passage this
26th day of September, 1978.
GLENN K. JARSTAD, MAYOR
ATTEST:
KATHLEEN L. MANDIO, CITY CLERK
C12~' OF BREMEF, TO~q
ISPORI OF INJURY TO EYTLOYEE
NAME POSITION OR JOB TITLE
ADDRESS HOME PHONE
DEPARTMENT EMPLOYED BY
I.~EDIATE SLiERVISOR TITLE
DATE & TIFfE OF INJURY: , 19 , AT A.M. - P.M. (X Olrr I)
DATE & TIME REPORTED , 19 , AT A.M. - P.M. (X OLrf 1)
TO ]~HOM REPORTED - NAME TITLE
ADDRESS 'AT W~ICH INJURY OCCLrRRED __
~rrh&T ~tLE ASSIGNED DUTIES AT THE TIME OF INJURY?
DESCRIBE THE INJURY
I~IAT CAUSED THE INJURY?
WAS A DOCTOR CALLED? IF SO, GIVE N~M]E ~J~D ADDRESS __
AND ~HEN DOCTOR SAW THE INJURED. DATE -
TIME - A.M. - P.M. (X OUT 1) WRITTEN REPORT OF DOCTOR M~jST BE OBTAINrED AND
ATTACHED, OR FUP~NISHED AS SOON AS AVAILABLE
HOW DID INJURED LEAVE THE SCENE OF THE ACCIDENT?
~rHERE WAS RE/SEE TAKEN OR WHERE DID HE/SHE GO? (X OUT 1)
NAMES AND ADDRESSES OF AN~' WITNESSES TO THE ACCIDENT OR INJURY?
NAME ADDRESS TITLE
(if a City employee)
(SIGNATURE OF INJURED PEPSON OR PERSON
ACTING IN BEHALF OF INJURED PERSON)
CORRECTI~ ~ASUKES TAKEN TO ELIMINATE CAUSES OF ACCIDENT
SUPERVISOR OR DEPARTMENT HEAD
ORIGINAL - CIVIL SERVICE OFFICE
1 COPY - INJURED EMPLOYEES DEPT.