AQPART A: wea 0/25/13 CITY OF WICHITA FALLS EMPLOYEE'S INJURY REPORT SUPERVISOR: This form is used to file an employee worker's compensation Ijury claim, To ensure a timely claim is fled ‘with the State, forward this form to Risk Management within 24 hours. it can be faxed to 761-7634. If additional time is needed to complete the signatures, and to answer questions on page 3 please note on form and forward ASAP. INJURED WORKER'S PERSONAL INFORMATION 7, Employee Name (Last, Middle Initial, First) 2 SSN 3. Employee ID # 4, Personal Phone Number: '5, Work Phone Number 9403972542 6. Date of Birth: 7. Personal Mailing Address- Street. 8. City, State and Zi ‘9, Does The Employee Speak English? yes T 70. Marital Status: 77. Spouse Name! 12. Number of Dependent Children: 73. Department/Division: 14, Date/Time Risk Notified? 15, Person in Risk Contacted: Waste Water 07/05/2016 11:00am 16. Date of Fire: 17, Years & Monihs in Current Position: | 76. Years & Months with the Git: 11/08/2007 Tyr 8mos 79, Days of the Week Employee Works: 1288 20, Hours Worked Per Shift & Weetly; 27. Employee's Hourly Wage: 18.008 22, Employee's Bi-Weekly Pay: 1498.43, 723, Gross Amount of Last Paycheck 1498.43 24, Did you or are you seeking medical care? yes 5, Where did you go for medical care? 26, Treating Doctors Name: Page 1PARTB: INJURED WORKER'S STATEMENT OF ACCIDENT- EMPLOYEE MUST COMPLETE Employee's Name Employee's Job Title Date and Time of Injury: Lead Operator 07/02/2016 2:30pm Date and Time Supervisor Notified: Name of Supervisor at the Time of Injury: | Were you working alone? no ‘Worksite location of injury (on the stairs, in the shop, in a field, etc.) Primary Basement Physical address of where injury occurred: 1005 River Road 76305 What body parts were inured? (Include al body parts effected, and the locaton be. right Tei, ont, back Sc) Lungs ‘What type of injury was sustained? (j-e. laceration, exposure, strain, break, heat stress, insect bite, etc.) Possible H2S inhalation Describe how injury occurred: (attach additional sheet if needed for a complete explanation) Inspecting a broken pump leak ‘What could have been done differently fo prevent this injury? ‘What personal protective equipment was in use al the time of injury? ‘Were any tools or equipment involved in injury? if so which ones? ‘What training was received to do the job being performed when injury occurred? ‘Was horseplay occurring on the jobsite when injury occurred? | Names of employees present at the time of injury: no The above statements are my own account. To the best of my knowledge they are accurate and complete. Signature pate 1: - 1b Injured Employ Page 2[PART SUPERVISOR'S STATEMENT Injured Employee Name: Date of injury ‘Supervisor Completing this section: -2-f6. _BL The ewTow luired to use when doing the task that caused the Injury and were they using them? Maree —Wargralle — Tppesine 2 wales af the eyfrance Did the actions of any other employee ibute to the caus this injury? (Explain if your answer is Yes) Mo Was the employee trained in the safely requirements needed to do this job? (Please provide documentation of such training) I Var Did the employee violate any written Safety policy? MO ‘CHECK ALL THAT APPLY Defective Equipment Unsafe process ‘Lack of communication Inadequate tools available |_| Poor ventilation ‘Operating at improper speed Poor lighting Inadequate supervision Improper use of tool i Thadequate wamnings (cones, lights)_| | PPE not used or was inadequate Poor housekeeping Inadequate PPE required Violated safety policy ‘Did not use mechanical guards Injury was caused by citizen Improper lifting Inappropriate use of equipment Defect in walking surface Improper bencing/twisting ‘Required equipment was not used “Tripping hazard not marked se the 3 point system Failure to secure | [inadequate warning signs Failure to warn/notifylignal id not follow equip. manufacture’s Missing or loose grates/covers ‘Other employees actions safely warnings Inadequate safely training Horseplay ‘Other: [Work station is not ergonomically Trip, slip and fall hazard left ‘Other |_| comect uncorrected Other: [Tack of written safety policy Did not properiy inspect equipment | | Other: Explain any items checked ‘What could have been done differently to prevent this injury? 6 bas detector wil be used Face try ‘Additional comments, ‘Supervisor Signature: Bll Le Date_ ZA 6%, Division Head Signature: Date: Department Director Signature: Date:, Page 3A10Jul 21 2016 0321PM CWF WW COLL REHAS 9403072549 page 1 a pi eS P40 9/25/33 CITY OF WICHITA FALLS EMPLOYEE'S INJURY REPORT SUPERVISOR: This form is used to file an employee worker's compensation injury claim. To ensure a timely claim Is filed with the State, forward this form to Risk Management within 24 HOUTS. It can be faxed to 781-7634. If additional time is needed to complete the signatures, and to answer questions on page 3 please note on form and forward ASAP, PART A: __ INJURED WORKER'S PERSONAL INFORMATION 1. Employes Name (Last, Middle initial, First 2 SSN S Employes 10 # ‘4. Personal Phone Number: 5. Work Phone Number: 6. Date of Birth: | Morass, —_— 8. City, Stato and Zip: . Doss The Employes Speak Engish? 17. Spouse Name: 72. Number of Dependent Children: = 13. Dapariment/Division: "| 74 Date/Time Risk Notified? 15. Person in Risk Contacted: (sta2 7/20/2016 11:00 am James Little 16. Date of Hire: 17. Years & Months in Current Position: | 18. Years & Months with the City: | 4/18/2016 3 months | 18, Days of the Week Employes Works: | 20. Hours Worked Per Shin & Weekly: | 21, Employee's Hourly Wage: 7 40 | 11.129 | 22. Employae's Bi-Weekly Pay: | 25. Gross Amount of Last Paycheck: | 24, Did you or are you seeking medical care? 4 Yes 25, Where did you go for medical care? [38 Treating 7h 7 Received = : Risk Mana: Page.Jul 21 2016 03:21PM CWF WwW COLL REHAB 9403972549 page 2 40 8/23/33 PART B: INJURED WORKER'S STATEMENT OF ACCIDENT- EMPLOYEE MUST COMPLETE Name Employeo's Job Tie 71-17 S77, _| Date and Time of fury Heavy Equipment Operator 7/20/2016 11:00 am Date ang Time Supenisor Notified: | Name of Supervisor at the Time of Irjury: | Were you working alone? —] 7/20/2016 12:30 pm __| Nicki Lowery no Werksis locaton of injury (on te star, inthe ehop, in afield, ota) Holiday creek Physical acdress of where injury occurred: off Midwestern ‘What body paris wore injured? (Include al body pars affected, and the louaion Le. High, Je, Font, Baak, B=) throat is sore ‘What ype of injury was sustained?” (Va, laceraion, exposure, eran, Broek, heat eiress, nGeat BTS, =) Theoat eritation ‘Describe how injury occurred: (attach additonal ah chemical inhalation from manhole ‘needed for a complete explanation) | What could have been done differently to prevent this injury? Second gas meter and resperator for the operator ‘What personal protective equipment was in use at the time ofinjury? bone ‘Ware any tools or equipment involved in injury? Wf so which ones? po ‘Wha training was received to do the job being parfornad when injury occurred? safely training Ta aR ETE RST i as pre a no Co The above statements are my own account To the bost of my Knawledge they are accurate and complete, z i Injured Employ Signatur Dat Page 2Jul 21 2016 0321PM CWF WW COLL REHAB 9403972549 P40 8/23/13 PART C: SUPERVISOR'S STATEMENT injured Employee Name: ] Date of mary Supervisor Completing Wis section: 7/20/2019 Nicki Lowery Cas Dcteote -, SCBA ‘What PPE would the employee be required to use when doing the task that caused the Injury and were they using them? Yes tho no Did the actions of any ther employee contribute to the cause of ths Injury? (Explain l' your answer Is Yes) ‘Was the employee trained in the safely requirements needed to do this|ob? (Please provide documentation of such walning) YES | Wezardons Communicatiin TRaoining Did the employee violate any written safety policy? no ‘CHECK ALL THAT APPLY Defective Equioment Unsafe process: Tack of communication Inadequate tools available Poor ventilation ‘Operating at improper speed [Poor tighting Inadequate supervision Improper use of toot Inadequate wamings (cones, lights) |x] PPE not used or was inadequate Poor housekeeping [x | Inadequate PPE required Violated safety poli ‘Did not use mechanical guards Injury was caused by citizen Improper iting Inappropriate use of equipment Defect in walking surface Improper bending/twisting Required equipment was not used “Tripping hazard not marked Dic not use the 3 point system Failure to secure Tnadequate warning signs Failure to warrynotify/signal ] Did not follow equip. manufactures Missing or loose gratesicovers ‘Otier employees actions safety wamings Inadequate safety training Horsepiay, ‘Other: Work station is not ergonomically Trip, sip and fall hazard left ‘Other: correct uncorrected ‘Other: Lack of writen safety policy Did not properly inspect equipment | | Other: Explain any items checked ‘operator was unaware of the gas in the area. Needed to have a second gas monitor. gas monitor | 380 scBA [ Whgt coukd have Been done aiferenty Yo prevent ts injury? ‘Additional comments: fuleroted up aind Employer viited Backhoe i mmebs Emologer wes in Ye Geckhoe with Deors closed & winleus Shud. Relieve gas to hm entered through A/c verdiletion - whey oret ges alarm wenaudible + Webs ‘Supervisor Signature: Reason Division Head Signature: Date:__‘]-0-/6 Date: 1-B0-¢6 Date:_7- 20-76 Page 3