Attachment 8 DISA inj.docm

JOB INJURY REPORT PACKAGE

DISA Defense Enterprise Computing Center – Columbus (DECC-C)

DISA DECC-C Safety Unit Managers:

Enterprise Operations – Toria Smith 2- 4390 (Bldg. 20) Lynny Mitchel (Bldg. 23) Enterprise Programs – Frank Titus 2-3115 (Bldg 20) Security – Nick Haskakas 2-0841 (Bldg. 20, 23) Business Office – Kevin Wright 2-4500 (Bldg. 20) Denise Pence 2-4591 (Bldg. 20, 23) NOC – Deb Wiseman 2-9182 (Bldg. 23) Clark Dickson (Shift C) 2-4790 (Bldg. 23) Sherman Jones (Shift B) 2-5110 (Bldg. 23) Vickie Abbott 2-9198 (Bldg.20) Janet Neff 2-0826 (Bldg.20)

Safety & Health Administrator, and POC for Command Office – Dan Nagle – 2-7144

Attached are accident, compensation and medical officer report forms that should be completed as indicated. A copy of the DISA FORM 73 is attached and can also be found in FormFlow.

EMPLOYEE’S INSTRUCTIONS

DSCC FORM 1157: Complete the top half of the attached DSCC Form 1157. Return the package to the attending medical authority, who will complete the bottom half of the form and provide treatment.

FORM CA-20: You are responsible for providing the treating physician with the Form CA-20. This form is used to obtain the necessary medical evidence to support the alleged injury/illness.

FORM CA-1: YOU ARE RESPONSIBLE FOR INITIATING THE FORM CA-1. The attached Form CA-1 must be completed for all injuries, no matter how minor the injury may seem. Fill in items 1 through 16 within two (2) working days and give it to your supervisor.

SUPERVISOR’S INSTRUCTIONS

FORM CA-1: The Supervisor or official superior is required to complete the reverse side (Items 17 through 38, as appropriate) of the Form CA-1. Return it to your Safety & Health Unit Manager within two (2) working days after receipt of the form from the employee. If you have any questions about this report, please call your Safety & Health Unit Manager.

DISA FORM 73: THE SUPERVISOR IS REQUIRED TO COMPLETE A DISA FORM 73, MISHAP REPORT FOR ALL MISHAPS. If your employee has been injured, contact your DISA Columbus Safety & Health Unit Manager immediately. The DISA Form 73 must be completed and forwarded to your Safety & Health Unit Manager within five (5) working days from the date of the mishap. Your Safety & Health Unit Manager will assist you in properly completing the DISA Form 73 and answer any questions you may have concerning your reporting responsibilities.

REMINDER TO MEDICAL OFFICER: Please remove the top 3 copies, for appropriate distribution of the DSCC Form 1157 and return the rest of the package to the employee for proper completion of the remaining forms.

ATTACHMENT 8