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Accident/Injury Employee Report


This electronic form MUST be completed by a Manager immediately following notification of an Employee Injury/Incident, regardless of how small or insignificant the injury/incident.

  • Call HR (Dianna Stepp, ext 0962 or Tricia Cutshall, ext 0269)
  • Call HR to inform of the injury/incident. The timeframe of this call should be done based on the seriousness of the injury.
  • Some clinics require the injured employee to bring a form with them. HR will provide you with that form, if it is required.

Drug Screen Required

The employee MUST complete a Drug Screen, within one hour of the injury/incident, regardless of whether or not they wish to seek medical treatment.
If the employee reports the incident more than one hour after the incident occurred, they must complete a Drug Screen within one hour of the report.


Workers’ Comp/Drug Screen Designated Facilities

Corinth:

  • First Action for Corinth Employees: Manager/Supervisor Must Call the Triage Nurse – MedCor (800) 775-5866; Triage Nurse will Provide Instruction
  • Treatment and/or Drug Screen: Physicians Urgent Care, 2601 Getwell Rd, Suite 1, Corinth

Florence:

  • Treatment and/or Drug Screen: Working Fit – Helen Keller Hospital, 1300 S Montgomery Ave, Sheffield

Hoover:

  • Treatment and/or Drug Screen: American Family Care (AFC Urgent Care), 1680 Montgomery Hwy, Vestavia Hills

Muscle Shoals:

  • Treatment and/or Drug Screen: Working Fit – Helen Keller Hospital, 1300 S Montgomery Ave, Sheffield

Prattville:

  • Treatment and/or Drug Screen: American Family Care (AFC Urgent Care), 1965 Cobbs Ford Rd, Prattville

Selma:

  • Treatment and/or Drug Screen: Selma Urgent Care, 1025 Medical Center Pkwy, Selma

If the injury warrants an ambulance, call 911 first.


Accident/Injury Employee Report

  • MM slash DD slash YYYY
  • MM slash DD slash YYYY
  • :
  • Accident Location Information

  • Person Injured Information

  • Witness Information

  • Accepted file types: jpg, tiff, pdf, doc, docx, xls, xlsx, Max. file size: 16 MB.
    If you would like to upload photos and/or supporting documents, please do so above. Acceptable file formats are jpg, tiff, pdf, doc, docx, xls, xlsx.