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IISD First Report of Injury
Irving ISD carries workers' compensation insurance for employees who may be injured on the job. If you are injured on the job, please complete the form below. Any questions may be directed to safety@irvingisd.net
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* Indicates required question
I am completing the form:
*
For myself
For someone else
If you are competing the form for someone else, please list your name and email.
Your answer
Injured Employee's First Name
*
Your answer
Middle Initial
Your answer
Last Name
*
Your answer
Employee Email Address
*
Your answer
Last four of SSN
*
Your answer
Gender
*
Male
Female
Date of Birth
*
MM
/
DD
/
YYYY
Irving ISD Employee Number
*
Your answer
Home Address
*
Your answer
Best contact number (XXX-XXX-XXXX)
*
Your answer
What campus/department were you injured at and where in or outside of the building did the injury occur.
*
Your answer
What date did the injury occur?
*
MM
/
DD
/
YYYY
What time did the injury occur?
*
Time
:
AM
PM
Employee's Department or Campus
*
Choose
914 Facility Services
916 Food Services
915 School Safety & Operations
926 Transportation
892 Athletics
002 Irving HS
003 MacArthur HS
004 Nimitz HS
005 Cardwell
006 Singley
009 SRC
041 Bowie MS
042 Crockett MS
043 Travis MS
044 Lamar MS
045 Austin MS
046 Houston MS
048 de Zavala MS
050 Johnson MS
101 Barton ES
102 Brown ES
105 Good ES
106 J. Haley ES
107 T. Haley ES
108 Johnston ES
109 Keyes ES
111 Lee ES
112 Lively ES
113 Farine ES
114 Schulze ES
116 Brandenburg ES
118 Elliott Admin Annex
119 Hanes ES
120 Townley ES
121 Davis ES
122 Gilbert ES
123 Townsell ES
124 Stipes ES
161 Clifton EC
162 Pierce EC
163 Kinkeade EC
164 BabyU
701 Superintendent
703 Tax Office
732 Risk Management
735 Business Office
737 Purchasing
739 Support Services
836 MAHI
848 Science Discovery Education
852 PEIMS
859 Digital Learning & Lrn Res
860 Technical Services
871 State & Federal Programs
872 School Leadership
880 Bilingual, ESL Language SRVCS
881 Guidance & Counseling
882 Gifted & Talented
883 Career & Technical Education
884 Special Education
886 Curriculum & Instruction
887 MTSS
888 Language & Parent Services
894 Campus Operations/Attendance
895 Learning Services
896 Learning Resources
897 Fine Arts & Enrichment
898 Professional Learning
899 Outdoor Learning Center
908 Information Technology SRVCS
909 Human Resources
911 Performance/Outcomes/Data
920 Health Services
922 Communications
Other
Name of employee's principal, supervisor or lead
*
Your answer
Your supervisor's email address
*
Your answer
I understand that I am required to notify my supervisor of the injury (if I have not already done so.)
*
Agree
Describe below how the incident occurred and state what the employee was doing when injured or ill. What was the injured employee doing at the time of the accident?
*
Your answer
Why did the accident occur?
*
Your answer
Did any staff witness the accident? If so, please list their names (and contact information if you have it).
*
Your answer
Indicate below what act(s), in your opinion, contributed to this accident
*
No wet floor sign posted
Not paying attention to surroundings
Did not know how to do correctly
Did not follow proper procedure
Improper pace or speed
Not wearing protective equipment
Improper use of body posture
Did not use proper equipment (step stool/ladder)
Did not follow buddy rule for lifting
Overhead reaching
Did not use handrail
Emotions were not under control
Unsafe area not properly secured
Safer act was less convenient
Using a cell phone
Carrying an oversized/unbalanced load
Obstructed view
Improper placement of objects on shelf
Other:
Required
If an employee is injured as the result of a physical assault during the performance of their duties, assault leave may be requested. An investigation of the incident will be conducted to confirm or deny assault leave status. Do you wish to file for Assault Leave?
*
Not applicable
No
Yes
What is the nature of the injury(ies)? Check all that apply.
*
Burn
Contusion (Bruise)
Crushed/pinched
Cut
Dermatitis
Electric shock
Foreign object/liquid
Fracture
Loss consciousness
Puncture
Severance
Sprain (joint)
Strain (muscle
Required
Has the injured employee sought medical care for this injury/illness?
*
Yes
No
Later if needed- and I understand I need to notify the risk management team if I choose to seek treatment at a later time
What [head] body parts were injured? Select all that apply.
*
Not injured on my head/ neck
Head - top
Forehead
Ear (lL)
Ear (R)
Eye (L)
Eye (R)
Nose
Cheek (L)
Cheek (R)
Jaw (L)
Jaw (R)
Mouth/teeth
Neck
Other:
Required
What [arm/hand] body parts were injured? Select all that apply.
*
Not injured on my arms/hands
Shoulder (L)
Upper Arm (L)
Elbow (L)
Lower Arm (L)
Wrist (L)
Hand (L)
Finger(s) (L)
Shoulder (R)
Upper Arm (R)
Elbow (R)
Lower Arm (R)
Wrist (R)
Hand (R)
Finger(s) (R)
Other:
Required
What [abdomen/back] body parts were injured? Select all that apply.
*
Not injured on my abdomen/back
Chest
Abdomen
Hip (L)
Groin (L)
Upper thigh (L)
Upper Back
Mid Back
Lower Back
Buttocks
Hip (R)
Groin (R)
Upper Thigh (R)
Other:
Required
What [legs/feet] body parts were injured? Select all that apply.
*
Not injured on my legs/feet
Thigh (L)
Knee (L)
Calf (L)
Ankle (L)
Foot (L)
Toe(s) (L)
Thigh (R)
Knee (R)
Ankle (R)
Foot (R)
Toe(s) (R)
Other:
Required
I understand if I seek treatment for a workers' compensation injury - I need to choose an Alliance Provider - https://www.pswca.org/find-a-provider.html
*
Yes
If you have sought treatment or plan to, please list the Alliance Provider you selected. https://www.pswca.org/find-a-provider.html
Your answer
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