Safety Reporting Forms

The following forms were approved by the Safety Committee for use as described below.  Contact information for the Insurance Liaison is:

Chris Henkel
112 E. Second Street
Dixon, IL  61021
(815)288-3643
This email address is being protected from spambots. You need JavaScript enabled to view it.
 

 

 

Confirmation of Transitional Duty/Return to Work Status is completed by the employee when returning to work following an injury or illness. 

Employee Incident Report is completed by the employee within 24 hours or as soon as possible following an injury/incident and retained by the County Officer/Department Head.

Hepatitis B Vaccine Declination is completed by an employee that declines the hepatitis B vaccination. (mandatory)

Illinois Form 45: Employers First Report of Injury is completed by the County Officer/Department Head and forwarded within 24 hours or as soon as possible to the Insurance Liaison for Claim Processing.  (Required by Gallagher Bassett Services to process an employee injury claim.)

Medical Authorization (Medical Records Release Form) is completed by the injured party only upon request of the insurance claims adjuster. 

New Employee Safety Orientation Checklist may be used by the County Officer, Supervisor, or Manager during orientation of a new employee. 

Non-Employee Injury Report is completed by the injured party (other than a county employee) and filed with the County Insurance Liaison within 24 hours or as soon as possible following the injury/incident. 

OSHA Form 300 - Log of Work Related Injuries and Illnesses is a US Department of Labor Occupational Safety and Health Administration (OSHA) form to be compiled and retained by the Insurance Liaison.  This form lists every work-related death, injury or illness that involves loss of consciousness, restricted work activity or job transfer, days away from work, or medical treatment beyond first aid. (See OSHA website for actual form.)

Property Damage Incident Report is completed by the County Officer/Department Head, the Insurance Liaison or other individual involved with property damage and filed within 24 hours or as soon as possible with the Insurance Liaison. 

Transitional Duty Guidelines Form is completed by the employee's physician when returning to work following an injury or illness.  It specifies what, if any work restrictions the employee shall follow. 

Witness Statement is completed by any/all witnesses to any type of incident within 24 hours or as soon as possible following the incident and retained by the County Officer/Department or Insurance Liaison.