Worksite Injury Reporting Checklist

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C-1 Form - Notice of Injury or Occupational Disease

The following is a list of injuries that should be reported to AdvanStaff HR immediately:

  • Death
  • Loss of consciousness
  • Injuries that cause missed days of work or restricted work activity
  • Any needle injury or cut from a sharp object that is contaminated with another person’s blood or any other potentially infectious material
  • Injuries that require an employee to be medically removed under the requirements of an OSHA health standard
  • Injuries that require any medical treatment beyond first aid (refer to the “Medical Treatment” vs. “First Aid” form)

Note:  If an injury which required only first aid is reported and there were no lost wages, it will not affect your workers’ compensation deductible; the accident report will only be kept for our records.

Accident Reporting Procedure

AdvanStaff HR enforces the following worksite accident / illness reporting policy:

The following steps are required in the event of a worksite or work-related injury or illness:

  1. Employee(s) must report any and all accidents / illness to their supervisors immediately.
  2. If the injury requires professional medical attention, a supervisor or a company representative should, whenever possible, accompany the injured worker to the medical care facility to ensure employee safety and that the appropriate forms are completed by the health care provider.  Please be aware that the employee may also be subject to drug and alcohol screening. For a list of Concentra Medical Facilities click the following:  LIST VIEW or MAP VIEW
  3. AdvanStaff HR requires verbal notification within 24 hours of the accident.  If your call is placed after work hours or during  a weekend or holiday, please leave a detailed voicemail message at (702) 598-0000.

  4. A C-1 Workers’ Compensation Incident Report Form must be completed and submitted as soon as possible immediately following the accident.  AdvanStaff  must receive this completed form within 48 hours of occurrence.  Any questions left unanswered will delay the claims process. 

    Fax the completed form to: (702) 598-0646
     Forms Download:
    C-1 Form - Notice of Injury or Occupational Disease C-1 Form – Notice of Injury or Occupational Disease (49.53 Kb)

  5. An AdvanStaff HR representative will contact you within 48 hours to discuss the accident.  AdvanStaff HR will contact your workers’ compensation insurance carrier to file a claim if necessary.  Please be aware that AdvanStaff HR and/or the insurance carrier may also contact the supervisor, the injured employee(s), or any witnesses to discuss the accident / illness in detail.

Following leave due to worksite injury, an employee must submit a return-to-duty authorization to AdvanStaff prior to returning to work.  This authorization must come from the injured employee’s attending physician.

 

Post-accident / Illness & Alcohol Testing

AdvanStaff HR is committed to fostering a safe work environment for all employees.  Therefore, the following post-accident/illness drug and alcohol testing policy has been established.

AdvanStaff HR will require a post-accident/illness drug and alcohol test for any employee involved in a reported accident if the following applies:

  • The accident involved a vehicle or any machinery
  • The accident resulted in property damage
  • The accident resulted in another individual’s death

AdvanStaff HR will coordinate all testing, assist in investigations and searches as privately as practical and permitted by applicable federal and/or state laws and regulations.  All results from drug and alcohol testing will be treated as confidential information.

If you employ commercial vehicle drivers, your substance abuse testing program must comply with the requirements of the U.S. Department of Transportation (DOT).  The DOT regulations specify when and how drivers must be tested and require certain consequences for violations.  If your company is DOT regulated, you are fully responsible for compliance.

 

Returning to Work

If an employee misses work due to a work-related injury or illness, they must obtain return-to-duty authorization from their attending physician in order to return to work.  This authorization must be submitted to the worksite employer for verification.  Once verified, the employee may be scheduled for work.  The employee may not return to work prior to receiving this notification from the physician, no matter how minor the injury appears to be.