Employee Accident - First Report of Employee Injury
| Unit # |
6010 (02-0013) 2407 N 14th St Ponca City, OK 74601 (580) 749-5944 |
| Date and Time of Accident | October 14, 2021, 10:13 p.m. |
| Employee Name (First and Last Name) |
Mela Lebeda
|
| Employee Address |
3068south Waverly St
|
| City/St/Zip |
Ponca City Ok 74601
|
| Employee Phone |
5803821952
|
| (Admin use only) | |
| Gender |
Female
|
| Date of Birth | December 14, 1999 |
| Job Title |
Crew
|
| Avg # of Days Employee Works Per Week | 5 |
| (Admin use only) | |
| Avg # of Hours Employee Works Per Week | 40 |
| FT or PT | Full-Time |
| Describe Accident |
Slipped and fell on floor in FOH going into lobby. She was Wearing nonslips. She landed on her back and hit her arm.
|
| Where in the facility did accident occur? |
FOH Going into lobby
|
| Please attach photo of the area accident occurred. | |
|
|
| Please take video of camera (if needed) of the accident. Note: Do not make comments while taping the video. | |
| What was employee doing at the time of the accident? |
Picking up Carpets
|
| Parts of body affected and nature of injury (specify Left or Right side of body) |
Left arm. Possibly Broke wrist or shoulder, fingers are going numb can not move it.
|
| Please take photo of injury as needed | |
|
|
| Was Employee wearing slip resistant shoes (look at tread)? | Yes |
| Brand |
TredSafe
|
| Did employee seek medical treatment? | Yes |
| Medical Facility Name |
Ponca City Alliance Health ER
|
| Address |
1900 North 14th
|
| Phone | 5807653321 |
| Is employee unable to work? | |
| If so, expected date of return | |
| Date Employee Hired | |
| Shift Working Time (ex: 8am-4pm) |
3-11
|
| Did employee finish shift? | No |
| Eyewitness Statement |
N/A
|
| Eyewitness Signature | |
| Eyewitness Name (First and Last Name) | |
| Manager on Duty (First and Last Name) |
Emily Armantrout
|
Manager on Duty Signature
|
|
| Date Reported to Safety Manager | October 14, 2021 |
