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 Grigsby, 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

Cullman:

• Treatment and/or Drug Screen: Cullman Occupational Health, 1958 AL Hwy 157, Cullman (M-TH 7:30am-5pm, Fri 7:30am-12:30pm)
• Treatment and/or Drug Screen: American Family Care, 1841 Cherokee Ave SW, Cullman (If injury occurs between 12:30pm Fri- Sat)

Florence:

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

Hoover:

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

Muscle Shoals:

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

Prattville:

• Treatment and/or Drug Screen: Eastside Family Care – 14 Mitylene Park Dr. Montgomery, AL

Tuscumbia:

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

Saturday Only

Alabaster, Calera, Cullman, Hoover, & Prattville:

• Treatment and/or Drug Screen: Closest American Family Care, with an onsite Physician

North Alabama:

• Treatment and/or Drug Screen: Med Plus in Florence, 2908 Mall Rd. Florence, AL

Managers- Call the appropriate treatment facility prior to sending your employee to ensure there is an onsite physician. When sending your employee, be sure you send them with a completed “Letter of Authorization” linked below.

If the injury warrants an ambulance, call 911 first.

!!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.