<p> FORT WORTH INDEPENDENT SCHOOL DISTRICT EMPLOYEE’S ON THE JOB ACCIDENT REPORT</p><p>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].</p><p>Name of Employee: ______Title: ______</p><p>Facility where accident occurred: ______</p><p>Date of accident: ____/____/____ Time of accident: _____:_____ am/pm</p><p>Has the accident been reported to your supervisor? YES or NO</p><p>Date reported to your supervisor: ____/____/____ Time: ____:____ am/pm</p><p>Location of incident within the facility (kitchen, classroom #, hallway #, outside (where?), etc. (be specific): ______</p><p>Were you injured? (circle one): Yes No</p><p>Body part(s) injured (be specific): ______</p><p>How did your accident happen? (Describe your accident in detail): ______</p><p>In your opinion, what was the cause of the accident? ______</p><p>What safety measures do you think can be taken to prevent an accident of this type? ______</p><p>IMPORTANT: The following information must be completed for accidents involving student interactions or dealing with disruptive behavior (breaking up</p><p>Revised March 2016 FORT WORTH INDEPENDENT SCHOOL DISTRICT EMPLOYEE’S ON THE JOB ACCIDENT REPORT</p><p> fights, bitten, scratched, or shoved by student, picking up/lifting student, assisting student, etc.)</p><p>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</p><p>Employee Signature Date ______</p><p>Revised March 2016</p>