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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 (Ashley Moody, ext. 0124 or Dianna Stepp, ext 0962)
  • 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

Alabaster:

  • Treatment and/or Drug Screen: Alabama Comp, 114 Wildwood Parkway, Birmingham

Calera:

  • Treatment and/or Drug Screen: Alabama Comp, 114 Wildwood Parkway, Birmingham

Florence:

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

Hoover:

  • Treatment and/or Drug Screen: Alabama Comp, 114 Wildwood Parkway, Birmingham

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

Tuscumbia:

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

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: 50 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.


!!ATTENTION!!  ADDITIONAL ACTION REQUIRED!

In addition to completing and submitting the report form above, there is additional form must be filled out, printed, signed by the injured employee, then given to their supervisor to sign and turn into HR.  Please click the button below to get the form.