Get Employee Notification Form - Avera Health - Avera

Filling out the Employee Notification Form - Avera Health - Avera is an important process for reporting workplace events. This guide provides a detailed, step-by-step approach to completing the form accurately and thoroughly, ensuring that all necessary information is captured.

Follow the steps to successfully complete the form.

1. Click the ‘Get Form’ button to access the Employee Notification Form and open it in your preferred editing tool.
2. Begin by filling out the demographic information section. Input your full name, the department you work in, your address, city, state, and zip code. Include your contact number – office, home, or cell – followed by your social security number and date of birth.
3. In the event detail section, describe the event or injury, including all symptoms as clearly and completely as possible. Specify whether the event occurred on employer premises, and indicate the county where it took place. If applicable, provide the name of the source patient for body fluid exposure and details about any sharps exposure, including brand name, type, size, and gauge.
4. Complete the event information section by noting the event date, time, and location. Write down which part of your body was affected, along with a description of all equipment, materials, or chemicals you were using when the incident occurred. Also, specify the activity you were engaged in at the time of the event and confirm whether you were performing your regular job duties.
5. Answer questions regarding employee safety. Indicate if safety equipment was provided and if you failed to use it. Describe the safety equipment you used, and confirm whether you followed the relevant policy or procedure. Include information about any past similar injuries or symptoms to the affected area and provide an explanation if applicable.
6. Offer your suggestions for preventing future similar events, and if you are currently employed elsewhere outside of Avera, provide the name of the organization and your duties there.
7. Complete the employee detail section by noting your education level, length of time in your current position, and employment status. Include your position title at the time of the event, average hours worked per week, the start time of your workday on the date of the event, and the date the event was reported to your supervisor.
8. Provide the name of your supervisor and the type of treatment you received for the injury. If you were treated, include the name of the treatment provider.
9. Sign and date the form to confirm your report. Your supervisor should also sign and date the form, along with an employee health or work comp coordinator. Make sure to notify the work comp coordinator or employee health prior to seeking treatment.
10. Once all sections are completed and accurate, save any changes made to the document. You can then download, print, or share the form as needed.

Complete your Employee Notification Form - Avera Health - Avera online to ensure your workplace event is recorded appropriately.