Workers Compensation

Idaho
Department of
Correction

Standard
Operating
Procedure

Human
Resource
Services
Control Number:
206.07.01.005
Version:
1.4
Page Number:
1 of 8
Adopted:
3-16-2010
Reviewed:
9-28-2010

Title:
Workers’ Compensation

This document was approved by Terri Tomisser, director of Human Resource
Services, on 9/28/10 (signature on file).
BOARD OF CORRECTION IDAPA RULE NUMBER
None
POLICY STATEMENT NUMBER 206
Attendance, Work Hours, Leaves, and Workers’ Compensation
POLICY DOCUMENT NUMBER 206
Attendance, Work Hours, Leaves, and Workers’ Compensation
DEFINITIONS
Compensatory Time (Comp-time): Overtime that is unpaid and become hours that
accumulate in an earned leave balance for the employee to take time off work with pay at a
later date.
Hours Worked: Hours actually spent in the performance of the employee’s job, excluding
holidays, vacation, sick leave or other approved leaves of absence, and excluding on-call
time.
Manager: An employee appointed to manage, direct, and control a designated work unit.
Managers include division chiefs, deputy division chiefs, facility heads, deputy wardens (or
second-in-commands), district managers, designated lieutenants, program managers, or
any appointed unit manager.
Overtime: Hours worked on holidays, and hours worked in excess of 40 hours in a set work
week. For law enforcement (L) coded positions (e.g., correctional and probation and parole
officers), overtime is hours worked in excess of 160 hours in a 28 consecutive day period.
Excluded are hours such as traded time and occasional or sporadic work that is specifically
excluded under federal law.
Work Week: A period of seven consecutive days beginning 12:01 a.m. Sunday and ending
12:00 p.m. Saturday.
PURPOSE
The purpose of this standard operating procedure (SOP) is to establish Idaho Department of
Correction (IDOC) guidelines and procedures to ensure eligible employees are afforded
every benefit provided to them for injuries and disabilities incurred in the course of
employment.
Control Number:
206.07.01.005
Version:
1.4
Title:
Workers’ Compensation
Page Number:
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SCOPE
This SOP applies to all IDOC employees but gives specific guidance to supervisors,
managers, or designees in reporting, processing, and otherwise resolving workers’
compensation claims.
RESPONSIBILITY
Director of Human Resource Services (HRS)
The director of HRS is responsible for providing guidance and interpretation to fulfill the
expectations of this SOP.
Managers
Managers (or designees) are responsible for:
• Determining safe work procedures
• Ensuring safe working conditions
• Ensuring that employees are adhering to the rules, guidance, and procedures
provided herein and in SOP 224.07.01.001, Safety and Accident Prevention (in
terms of reporting, processing, and follow-up needed when an employee is injured
while working).
Supervisors
Supervisors (or designees) are responsible for ensuring employees are adhering to the
rules, guidance, and procedures provided herein and in SOP 224.07.01.001, Safety and
Accident Prevention, to include collaborating with the HRS to ensure a safe workplace
and timely handling and reporting of injuries.
Employees
Employees are responsible for adhering to the rules, guidance, and procedures provided
herein to include:
• Adhering to safety and security standards
• Timely reporting of injuries to their supervisors (or designees)
• Working with supervisors (or designees) and HRS to provide required medical
documentation used to resolve their workers’ compensation matter
Table of Contents
General Requirements ......................................................................................................... 3
1. Introduction .................................................................................................................... 3
2. Prompt Care for an Injured Employee............................................................................. 3
3. Investigation and Reporting the Occurrence ................................................................... 3
First Report of Injury or Illness (FROI) ...................................................................... 3
Supervisor’s Accident Report (SAR) ......................................................................... 4
4. Use of Leave in a Workers’ Compensation Claim ........................................................... 4
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5. Procedures for Coding I-Time ......................................................................................... 4
LWA or FJL Coding Example .................................................................................... 5
6. Return to Work Release ................................................................................................. 5
No Restrictions ......................................................................................................... 5
Modified Duty or Other Accommodations .................................................................. 5
7. Layoff after 12 Weeks of Disability .................................................................................. 5
8. Process Steps ................................................................................................................ 6
References ........................................................................................................................... 8
GENERAL REQUIREMENTS
1. Introduction
When an accident occurs in the workplace and results in an injury, managers (or designees)
will take immediate action to care for the employee, investigate what occurred, and work
with HRS to notify the Idaho State Insurance Fund (SIF) and, wherever possible, facilitate
the employee’s return to work.
For non-injury accidents, managers (or designees) will adhere to SOP 224.07.01.001,
Safety and Accident Prevention.
2. Prompt Care for an Injured Employee
When an accident occurs, the employee and his supervisor (or designee) will make an
immediate injury assessment based on available resources and training and provide
medical attention.
The employee’s supervisor (or designee) will also arrange for transportation to a medical
facility as necessary.
3. Investigation and Reporting the Occurrence
After an accident, the employee’s supervisor (or designee) will arrange for an immediate
investigation to include documenting details (e.g., the facts, the injured employee and
witness names and statements). The supervisor (or designee) will also notify HRS of the
accident. Two key reporting components will be the:
First Report of Injury or Illness (FROI)
It is recommended that the employee complete an HR-11, First Report of Injury or
Illness, whenever possible. If the employee is unable to complete the FROI a supervisor
(or designee) will assist. The supervisor (or designee) may also assist for the sake of
timely reporting. However, in no case will a medical provider complete the FROI.
Once completed, the FROI must be sent to HRS in accordance with section 8. HRS will
evaluate the FROI to ensure that it has been completed accurately and submit it to the
SIF in accordance with section 8.
Note: The SIF will determine the legitimacy or coverage of the claim. In no case will the
IDOC make a determination of coverage or denial.
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1.4
Title:
Workers’ Compensation
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Supervisor’s Accident Report (SAR)
The assigned supervisor, manager, or designee will immediately and fully complete an
HR-12, Supervisor’s Accident Report, to support the FROI. The supervisor, manager, or
designee will be responsible for (1) analyzing the incident and injuries, and (2) identify
what corrective or preventative actions will reduce the likelihood of future incidents.
Once completed, the SAR must be sent to HRS in accordance with section 8. HRS will
evaluate the SAR in accordance with section 8.
Note: The supervisor, manager, or designee will in no way attempt to make a
determination of coverage or validity of injury. Determination of coverage will be
determined solely by the SIF.
4. Use of Leave in a Workers’ Compensation Claim
When the SIF determines that the employee’s injury is eligible for workers’ compensation,
the employee will decide from the following leave options:
• Leave without pay (LWOP) while receiving workers’ compensation
• The use of accrued leaves (e.g., sick, compensatory time [comp-time], or vacation)
to supplement workers’ compensation in order to maintain his regular salary.
However:
♦ No supervisor, manager, or designee will require the employee to accept
sick, vacation, or comp-time off for overtime in lieu of workers’ compensation
♦ The employee cannot (1) waive his rights to workers’ compensation or (2)
accept earned leave or other benefits in lieu thereof.
Note: Employee medical benefits are not paid by the SIF. When the employee takes
LWOP, he must make arrangement with HRS to pay his portion of the medical
benefit premiums.
5. Procedures for Coding I-Time
Note: I-time refers to the state of Idaho’s online time entry system.
When entering hours for a workers’ compensation incident, I-time must reflect the number of
hours normally worked by the employee. The total hours worked will be comprised of:
• The total hours paid by the SIF (also see the table in this section)
• Any accrued leave (e.g., sick, compensatory time [comp-time], or vacation) the
employee is using to maintain his regular salary
• LWOP
The correct coding for I-time will depend on several factors (e.g., the employee’s available
accrued leaves, Family and Medical Leave Act (FMLA) leave eligibility, and the employee’s
salary). Therefore, it is highly recommended that the employee or supervisor (or designee)
consult with HRS to ensure the correct coding is used.
For the first five (5) days that the employee is off from work due to a workers’ compensation
injury, the SIF will not pay loss of income benefits. Therefore, the employee or supervisor (or
designee) must code I-time as sick leave taken (SIC), and document in the comments
section of I-time “out due to worker’s compensation injury” (or words to that effect). If SIC is
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Page Number:
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coded in I-time and the employee does not have enough sick leave hours available, I-time
will deduct from another applicable and available leave balance in accordance with SOP
206.07.01.002, Paid Leaves.
If the SIF determines that the employee’s injury is a covered workers’ compensation injury,
the SIF will pay 67% of the employee’s lost wages (tax free) up to a maximum weekly
amount of five hundred and seventy-two dollars and forty cents ($572.40). The following
table will assist the employee or supervisor (or designee) in determining how many hours to
code for LWOP on the job accident (LWA) or family medical, on the job accident, LWOP
(FJL).
Note: The employee must exhaust all accrued leaves before coding LWA or FJL.
LWA or FJL Coding Example
# of Hours and
Employee Normally
Works in a Day
Formula Hours Coded as LWA or FJL
(What the SIF Pays)
4 4 x .67 2.7
8 8 x .67 5.4
10 10 x .67 6.7
12 12 x .67 8.0
6. Return to Work Release
Prior to returning from leave due to a workers’ compensation injury, the employee will be
required to provide a return to work release to his immediate manager (or designee) in
accordance with SOP 206.07.01.002, Paid Leaves.
No Restrictions
If the return to work release indicates that the employee can perform his job with no
restrictions, the immediate manager (or designee) may schedule the employee to full
duty and forward the release to HRS for filing in the employee’s medical file.
Modified Duty or Other Accommodations
If the return to work release indicates that the employee can perform his job, but restricts
or limits any activity that keeps the employee from fully performing the essential
functions of his position, the immediate manager (or designee) will follow the ‘modified
duty requests and accommodation’ process described in SOP 206.07.01.002. Upon
receipt, the immediate manager (or designee) will forward the release to HRS for filing in
the employee’s medical file.
7. Layoff after 12 Weeks of Disability
If an employee becomes disabled, whether or not due to a workers’ compensation injury,
and is unable to return to work after 12 weeks or when accrued sick leave has been
exhausted (whichever is longer), the employee’s position may be declared vacant (unless
otherwise prohibited by State of Idaho or federal law).
For a period of one year from the date the position was declared vacant, the employee’s
name can be certified to a reemployment preference register when the Idaho Division of
Human Resources (DHR) has been notified by the employee’s medical practitioner that the
employee is able to return to work.
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If the employee is not eligible for protection under the FMLA (see SOP 206.07.01.004,
Family and Medical Leave Act [FMLA] Leave), the employee is entitled to take a maximum
of 12 consecutive weeks off from work due to his disability every 12-month period. The 12
consecutive weeks will not be interrupted for either of the following situations:
• When the employee fully returns to work (i.e., he is not approved for modified duty or
accommodation) for less than two weeks due to complications resulting from the
disability
• When the employee’s return to work is part of a rehabilitation program. (IDAPA
15.04.01, sections 241.01 and 241.02)
8. Process Steps
When completing, submitting, and processing the FROI and SAR, the following process
steps will be used:
Functional Roles and
Responsibilities Step Tasks
Employee (or
Supervisor) 1
In the event an accident resulting in injury or loss of time
occurs, immediately complete an HR-11, First Report of
Injury or Illness, and immediately submit to your supervisor
(or designee). Also see step 4.
Note: If the employee is unable to complete the First
Report of Injury or Illness (FROI), the supervisor (or
designee) will complete the FROI and proceed to step 2.
(For instruction on how to complete the FROI, see
appendix 1, Guidance Workers’ Comp Injury/Illness
Reports.)
Supervisor, Manager,
or Designee 2
• Immediately complete an HR-12, Supervisor’s
Accident Report, emphasizing the section entitled
‘Supervisor Analysis of Accident/incident/injury’.
(Include the specific details and corrective action to
prevent future incidents.)
• Within two working days from the incident, forward
the Supervisor’s Accident Report (SAR) and FROI to
Human Resource Services (HRS).
Note: For instruction on how to complete the SAR, see
appendix 1, Guidance Workers’ Comp Injury/Illness
Reports.
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1.4
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Functional Roles and
Responsibilities Step Tasks
HRS 3
Evaluate the forms for accuracy and compliance, log the
information in tracking sheet, and if the accident results in:
• Medical treatment or loss of time – forward the
reports to the Idaho State Insurance Fund (SIF) for
processing the claim. (The process skips to step 6.)
• No medical treatment or loss of time – file the
reports in the employee’s medical file, and send an
email notification to affected parties to notify HRS if
treatment should later be required. (Proceed to step
7.)
Note: The FROI must be submitted to the SIF as soon as
practical but not later than 10 working days after the
occurrence or knowledge of an injury or occupational
disease.
Employee (or
Supervisor) 4
If the employee later requires treatment, notify HRS within
two working days of the treatment sought and where
treated.
HRS 5
• Revise the FROI with medical information,
• Notify and forward the FROI to the SIF
• Update tracking log
• Assist the employee and/or supervisor with leave
options and advise on how to correctly code I-time
Note: I-time refers to the state of Idaho’s online time entry
system.
SIF 6
Assigns a claim number and adjuster. The claim is then
processed and copies of the documentation are forwarded
to HRS.
HRS 7
Continue to monitor and update the employee’s absence
and if the employee:
• Receives a full release--work with the supervisor to
facilitate returning the employee to his position. (See
section 6 of this standard operating procedure
[SOP].)
• Receives a modified duty request--provide
guidance to the employee and supervisor and
facilitate the modified duty process. (See section 6 of
this SOP.)
• Is unable to return to work--provide guidance and
ensure compliance with Family and Medical Leave
Act (FMLA), Americans with Disabilities Act (ADA)
(42 USC 12101 et seq.), short term or long-term
disability, and/or medical layoff or separation
processes.
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Version:
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Title:
Workers’ Compensation
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Functional Roles and
Responsibilities Step Tasks
SIF 8
At such point when the SIF determines the claim is closed,
the SIF will send notification to the employee and HRS with
instructions on how to notify the SIF in the event of any
future treatment.
HRS 9
Upon receiving notification from the SIF that the claim is
closed, close the tracking log, place the documentation in
the employee’s medical file, and close processing of the
file.
Note: In the event treatment is later required, the process
reverts back to step 5 until the claim is concluded.

REFERENCES
Appendix 1, Guidance Workers’ Comp Injury/Illness Reports
Code of Federal Regulation, Title 29, Chapter V, Part 825, The Family and Medical Leave
Act of 1993
HR-11, First Report of Injury or Illness
HR-12, Supervisor’s Accident Report
Idaho Code 72-602, Employers’ Notice of Injury and Reports
Idaho Code, Title 72, Worker’s Compensation and Related Laws—Industrial Commission
IDAPA 15.04.01, Rules of the Division of Human Resources and Personnel Commission,
Section 241, Workers Compensation and Disability
IDAPA 15.04.01, Rules of the Division of Human Resources and Personnel Commission,
Section 241.01, Use of Leave in Workers Compensation Claim
IDAPA 15.04.01, Rules of the Division of Human Resources and Personnel Commission,
Section 241.02, Layoff after Twelve Weeks’ Disability
Standard Operating Procedure 206.07.01.002, Paid Leaves
Standard Operating Procedure 206.07.01.004, Family and Medical Leave Act (FMLA) Leave
Standard Operating Procedure 224, Safety and Accident Prevention
State of Idaho, Idaho State Insurance Fund (www.idahosif.org)
United States Code, Title 29, Chapter 28, Family and Medical Leave
United States Code, Title 42, Chapter 126, Equal Opportunity for Individuals with Disabilities
– End of Document –
IDAHO DEPARTMENT OF CORRECTION
Guidance Workers’ Comp Injury/Illness Reports
Appendix 1 Page 1 of 4
206.07.01.005
(Appendix last updated 9/28/10)

If you have any questions about how the HR-11, First Report of Injury or Illness (FROI), or HR-12, Supervisor’s
Accident Report (SAR), should be completed, contact the HRS benefits specialist.

Important Issues about Workers’ Comp (WC) Claims

• We have a deadline (per Idaho Code) to file the WC claim 10 working days after the accident or injury.
The Industrial Commission does audit these dates, so it is very important that HRS receives the reports
as soon as possible after the date of injury to comply.
• The reports should be completed the day of the injury or as soon as possible after.
• Always complete the reports whether or not the employee seeks medical attention or has any loss of
time.
• It is not up to IDOC to determine if an injury will be covered or if it a legitimate WC claim. The Idaho State
Insurance Fund (SIF) will make that determination. We cannot deny an employee completing a report.
• It is important to note if the employee has any loss of time.
• Be as detailed as you can on the reports. It is very helpful for the WC claim adjuster to know exactly how
the injury occurred, who was involved and if there were any witnesses involved.
• Always complete the medical section. If medical treatment was not required, then mark “No Medical
Treatment”. Do not just leave it blank.
• If the reports indicate that no medical treatment was required and then, later, it is determined medical
treatment is necessary, notify HRS so that the reports can then be sent into the SIF.

Process Steps for Workers’ Comp (WC) Claims

• Every on-the-job injury requires an FROI and a SAR, whether or not medical treatment is required or loss
of time occurs.
• Whenever possible, the employee completes the FROI and the supervisor completes the SAR.
• If the employee is unavailable or unable to complete the FROI, the FROI must be completed by the
supervisor or appropriate person identified by the facility.
• The reports need to be sent to HRS via fax, email, mail) as soon as possible preferably within two (2)
days of the incident.
• HRS will audit the reports and add any missing information.
• The injury is logged into a tracking sheet.
• If there is a WC claim (medical treatment or loss of time), the reports will be faxed to the SIF.
• The reports will be filed in the employee’s medical file.

See the sample FROI that follows on the next page.

Appendix 1 Page 2 of 4
206.07.01.005
(Appendix last updated 9/28/10)
Blue text is entered by HRS.
Red text is completed by the employee and/or supervisor.

Each section has been broken out and filled in as an example for you to use. The sections are:
Employer
Employee
Wages
Accident or Illness
Medical
Preparer

Sample- First Report of Injury or Illness (FROI)-Sample

Every work injury that requires medical services other than first aid treatment must be reported within 10 days after the employer has knowledge of the injury. Filing this
form is not an admission of liability. This report shall not be evidence of any fact stated herein in any proceeding in respect of the injury, illness or death on account of
which this report is made.
E
M
P
L
O
Y
E
R
Employer’s name: Idaho Dept of Correction Employer status
Address: 1299 N Orchard St Suite 110 Sole Proprietor LLC Public
City: Boise State: ID ZIP: 83706 Partnership Corporation
Other
Phone #: [phone] FAX # : [phone] Is injured worker a Corporate Officer,
Partner, LLC member or Sole Proprietor?
Yes No Employer’s location address (if different) North Idaho Correctional Institution (NICI)
Address: 236 Radar Rd If a Sole Proprietorship, is the injured
worker a household member? Yes
No City: Cottonwood State: ID ZIP: 83522
Policy number: 022280 Organization code: 5270
The policy number for agency 230 is 022280.
The policy number for agency 231 (CI) is 439450.
The policy number for agency 232 (PC) is 628908.
The organization code is the employee’s pay location.

E
M
P
L
O
Y
E
E
Employee’s last name: Doe State where hired: Idaho
Employee’s first name: Jane Occupation: Corr Officer
Address: 12345 Paradise Loop Employment status: Current
City: Cottonwood State: ID ZIP: 83522 Sex Female Male
Phone # : [phone] Social Security # : 123-45-6789
Date of birth: 05/05/75 Date hired: 01/01/00
Under what class code were wages reported? 7720 Injury date: 01/16/08
Regular department: Marital status Single Widowed Other Married Separated

Text in red must be input by employee and supervisor.
Employment status is either current or separated.

W
A
G
E
S
Wage rate $ 12.74 per Hour Day Week Month Other Hours worked per week: 40
# of days worked per week: 5 Full pay for the day of injury? Yes No Did salary continue? Yes No
If board, lodging or other advantages furnished in addition to wages, give estimated value per week. $
If gratuities (tips, etc.) were received in the course of employment, give estimated value per week. $

Enter the employee’s hourly wage rate and days worked per week.
For example, 5 8-hour days or 4 10-hour days.
Can only indicate a maximum of 40 hours a week.

Appendix 1 Page 3 of 4
206.07.01.005
(Appendix last updated 9/28/10)

A
C
C
I
D
E
N
T

O
R

I
L
L
N
E
S
S

Place of accident or exposure (address): 236 Radar Rd, Cottonwood City/State: Cottonwood , ID
County: Did injury/illness occur on the employer’s premises? Yes No
Time injury occurred: 0915 AM PM Time employee began work: 0700 AM PM
Date last worked: 01/16/08 Date employer notified: see note below** Date disability began:
Date returned to work: 01/16/08 If fatal, date of death: Injury type (strain, cut, etc.): Cut
Part of body affected: Right arm Body part injured before? Yes No
Injury reported to (name and phone #) : Sgt. Perfect, 962-3276
Equipment, materials, or chemicals employee was using upon occurrence: IF applicable
How injury or illness occurred (Describe the sequence of events. Include objects or substances that directly caused the injury)
Officer Jane Doe was assisting with moving an inmate down the hall and ran into a metal box attached to
the wall, cutting her right arm just below her right shoulder. The cut was approximately 2 inches long and
bled profusely.

Was accident caused by the failure of a machine or product? Yes No Was safety equipment provided? Yes No
If the accident was caused by any person or business other than the injured worker, co-
worker or the employer, please identify.
Fill this in if an inmate caused the injury.
Was it used? Yes No
Were other workers also injured? Yes No
List other workers’ names:

Provide as much detail as possible!
**Date employer notified should be the same day as the injury.
If employee has missed up to 1 day or more due to the injury,
the claim must be submitted even if the employee did not
seek medical attention.

M
E
D
Physician or hospital (name and address)

Officer Doe was sent to Primary Health for evaluation and
stitches. She returned to duty later in the day.
No medical treatment Minor by employer
Minor – clinic/hospital Emergency care
Anticipated major med/time loss Hospitalized overnight
Did anyone witness the accident? Yes No If yes, provide name, phone # : CO Rodger Dodger, 962.0000
Preparer’s name and title: Sgt. Will B. Perfect
Preparer’s phone number: 962-3276 Date prepared: 01/16/08

This medical section must be filled out, even if no medical treatment was given. It needs to be complete.

If this is marked ‘no medical treatment’ or is left blank. The report will be logged into a spreadsheet in HRS but
will not be sent in to the SIF. However, if treatment is received later, please inform HRS so the report can then
be faxed to the SIF.

Supervisor’s Accident Report (SAR)

The IDOC also requires an SAR to support the FROI. This helps to validate the fact that the injury or illness is
work related. It also indicates that staff are committed to analyzing the incident and better prepare to avoid
such injuries in the future.

The FROI can be sent into HRS to be logged, and then sent on to the SIF as soon as it is received. However, it
is better to send both reports at the same time. If that is not possible at the time the FROI is submitted, you
must still submit the SAR.

See the sample SAR that follows on the next page.

Appendix 1 Page 4 of 4
206.07.01.005
(Appendix last updated 9/28/10)
Red text is completed by the employee and/or supervisor.
Sample- Supervisor’s Accident Report (SAR)-Sample

Name of Employee: Jane Doe Time in Position: 11 years
Date/Time of Injury: 01/16/08____ 09:15 am Location: NICI
Job Title: Correctional Officer Where did injury occur: Hallway outside Medical unit

Will you complete your shift? Yes Doctor care needed? Yes
When did you notify your supervisor about this injury? Date/Time: 01/16/08___ 09:25 am
Name of Supervisor contacted: Sgt. Will B. Perfect
Witnesses: CO Rodger Dodger

Part of Body Injured Nature of Injury
Head Upper Back Abrasion
Face Lower Back Laceration
Right Eye Right Leg Puncture
Left Eye Left Leg Bruise
Neck Right Knee Fracture
Chest Left Knee Sprain/Strain
Right Arm Right Ankle Dislocation
Left Arm Left Ankle Foreign Body
Right Hand Right Foot Burn
Left Hand Left Foot Skin (irritation)
Right Finger(s) Right Toe(s) Occupational illness
Left Finger(s) Left Toe(s) Loss of consciousness
Right Wrist Broken Glasses
Left Wrist Other
Was first aid applied? Yes If yes, by whom: CMS Nurse Nightingale

Employee description of accident. Describe the nature of the injury; provide details of what you were doing, what
materials/objects/machines were involved, if inmates were involved, who:
I was assisting with moving an inmate down the hall and ran into a metal box attached to the wall, cutting my
right arm just below my right shoulder. The cut was approximately 2 inches long and bled profusely. CMS Nurse
Nightingale administered first aid and recommended I be taken to a medical facility for stitches that may be
required. CO Rodger Dodger drove me to Primary Health, where stitches were done. Both of us returned to
complete our duty today.

Supervisor analysis of accident/incident/injury. Be specific in analysis. What corrective action has been suggested/implemented to
prevent similar accidents/incidents/injury:
Officer Doe suggested that the metal box be moved to a different location or that the corners have protective
padding. After reviewing the incident and the location of the box, it was determined that the box could be moved
to a location that does not interfere with people moving down the hall. The box was moved to the new location
the same day.

Employee signature: ______C O Jane Doe____________________________ Date: 01/16/08

Supervisor signature: ______Sgt Will B.Perfect ______________________ Date: 01/16/08

In this example, the accident is clearly explained by the employee.

In the analysis section, the supervisor documents corrective action that was suggested and implemented to prevent
similar injuries. This section is carefully evaluated by the SIF risk management representative to determine what is being
done by staff to provide as safe a working place as possible. Failure to offer corrective action reflects adversely on the
IDOC.