Fort Worth Independent School District

FORT WORTH INDEPENDENT SCHOOL DISTRICT EMPLOYEE’S ON THE JOB ACCIDENT REPORT

Instructions: This form is to be completed in detail by the employee WITHIN 48 HOURS of an accident. A copy is to be sent to the District’s Workers Compensation Office. FAX to 214-492-5691 or scan to [email protected].

Name of Employee: ______Title: ______

Facility where accident occurred: ______

Date of accident: ____/____/____ Time of accident: _____:_____ am/pm

Has the accident been reported to your supervisor? YES or NO

Date reported to your supervisor: ____/____/____ Time: ____:____ am/pm

Location of incident within the facility (kitchen, classroom #, hallway #, outside (where?), etc. (be specific): ______

Were you injured? (circle one): Yes No

Body part(s) injured (be specific): ______

How did your accident happen? (Describe your accident in detail): ______

In your opinion, what was the cause of the accident? ______

What safety measures do you think can be taken to prevent an accident of this type? ______

IMPORTANT: The following information must be completed for accidents involving student interactions or dealing with disruptive behavior (breaking up

Revised March 2016 FORT WORTH INDEPENDENT SCHOOL DISTRICT EMPLOYEE’S ON THE JOB ACCIDENT REPORT

fights, bitten, scratched, or shoved by student, picking up/lifting student, assisting student, etc.)

Student Status: General or Special Education: ______Grade Level: ______If the student is Special Education, circle the setting: LINC TAP SEAS Has employee been trained in TBSI? Circle: Yes No Is employee currently trained in CPI? Circle Yes No

Employee Signature Date ______

Revised March 2016