Supervisor's Workers' Compensation Incident Feedback Response
Employee's name__________________________________________________
Dates of incidents__________________________________________________
Unit/department___________________________________________________
Following is a summary of the discussion relating to the above employee incidents:
__________________________________________________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
________________________________________________ __________
Employee's signature Date
________________________________________________ __________
First-line supervisor's signature Date
I have reviewed the above summary:
________________________________________________ __________
Unit director/department head or acting designee's signature Date
Please return this completed form to the Office of Risk Management within the designated time frame.
SUGGESTIONS FOR FEEDBACK RESPONSES
________________________________________________
Above-named employee has had four workers' compensation-related incidents within a six-month period. They were all a result of resident-to-employee altercations. Employee stated his last ACT training was completed on 03/21/91 and wishes to attend the next class. He is scheduled to attend the next ACT class on 04/02/95.
________________________________________________
Above-named employee has had two workers' compensation-related incidents within a six-month period. Both of these incidents were related to lifting objects. Employee stated it has been more than three years since his last training. I have scheduled this employee to attend the next Lifting/Body Mechanics class in Staff Development on 04/18/95.
________________________________________________
Above-named employee has had three workers' compensation-related incidents within a six-month period. The incidents were unrelated and do not reflect any trends. The safety awareness has
been discussed with the employee, and we both agree no further action is required at this time.
________________________________________________
Above-named employee has had two workers' compensation-related incidents within a six-month period. Both incidents were due to human error. After discussing these concerns, we both agreed it would be beneficial for her to attend the next Safety Awareness class in Staff Development on 04/13/95.
________________________________________________
Above-named employee has had three workers' compensation-related incidents within a six-month period. All incidents were related to resident transfers/ambulation. Employee stated he is new on this unit and never had training on proper techniques. This employee is scheduled to attend the next Transfers and Ambulation class in Staff Development on 04/22/95.
________________________________________________
Above-named employee has had two workers' compensation-related incidents within a six-month period. Both were the result of resident-to-employee altercations. The employee last attended ACT training on 12/08/94. He is currently on the light-duty program and no further action is required at this time.
________________________________________________
Above-named employee has had four workers' compensation-related incidents within a six-month period. The prevention training for this employee is current for these types of incidents; however, there are other personal concerns. After a lengthy discussion, employee has been referred to the Employee Assistance Program for assistance.
Source: Richard Wilhelms, Health & Rehabilitative Services, Florida State Hospital, Chattahoochee.
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