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Supervisor's Injury/Illness Report Form

 

Student Enrollment

This report is to be completed by the Supervisor. This is a confidential report for HRD use.

Required

 

 

 

Employee Information

Injured Employee Namerequired
First Name
Middle (optional)
Last Name
Must contain a date in M/D/YYYY format
Must contain a date in M/D/YYYY format
0 / 5000
0 / 5000
Was personal protective equipment (PPE) required?required
0 / 1000
Was personal protective equipment (PPE) provided?required
0 / 1000
Was personal protective equipment (PPE) being used?required
0 / 1000
0 / 5000
Was safety training provided to the injured employee?required
0 / 1000
Will a service ticket be submitted for remediation of safety concern/hazard?requiredNote: If marked "Yes", include risk@vusd.org when submitting the ticket.
Note: If marked "Yes", include risk@vusd.org when submitting the ticket.
0 / 5000
Was this injury/illness a result of a Workplace Violence Incident?required
Has this type of incident occurred before at the workplace?required

 

What was the site's post-incident response?

Was emergency services and/or the YSO contacted?required
Was post-trauma counseling provided to affected staff who desired it?required
Was the district's Employee Assistance Program (EAP) provided to employee?required
Has there been follow-up with the employee(s)?required

 

 

Electronic Signaturerequired
Signature:required
First Name
Middle (optional)
Last Name
(Must contain a date in M/D/YYYY format)

 

 

Your Benefit Technicians

Need Help? Have Questions?

Find your designated benefits technician serving alphabetically by last name.

Marlen Allende

HRD BENEFITS TECHNICIAN
Serving Names: A-EH
Office: 559-730-7538
Extension: 11362
Main: (559) 730-7300

Christina Gonzalez

BENEFITS TECHNICIAN
Serving Names: EI-K
Office: (559) 931-8120
Extension: 11363

Jenny Cristallo

HRD BENEFITS TECHNICIAN
Serving Names: L-RAM
Office: 559-622-3460
Extension: 11364
Main: (559) 730-7300

Jennifer Ferguson

BENEFITS TECHNICIAN
Serving Names: RAN-Z
Office: (559) 931-8120
Extension: 11365