ࡱ> :=9O Ubjbj .eep  [[[[[ooo8$o&t$P![///[[/F[[/Buj0&!!![x>,$$H&////! !:  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 Districts Workers Compensation Office. FAX to 214-492-5691 or scan to fortworthisd@tristargroup.net. 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 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? 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