Sample Policy for Accident/Incident Investigation Procedure (Workers’ Compensation)

Disclaimer: This document is for example only and should not be used as a final product. The specific needs, practices, form of government and other operational procedures of your governmental entity may impact whether this example is appropriate for your use. PennPRIME strongly recommends that your solicitor and/or a qualified subject matter expert review the final product before it is enacted.

Please note the following sample investigation procedure must be modified to suit your specific situation. You may also develop your own procedure from scratch.

The procedure needs to include forms that will identify contributing factors and corrective actions. Please click here  (and scroll down to LCS#4) for Sample Accident Investigation Forms or utilize your own forms.

1. Injured employee is responsible for completing initial form, [insert the name of your entity’s form and the location where it can be found] and submitting it immediately to [insert title of person responsible for inputting claims for your entity] and their immediate supervisor.
2. [Insert title of responsible person] will insure paperwork is complete and submitted to Inservco within 24 hours. [Insert title of responsible person] will forward paperwork to [insert titles of ALL responsible persons/committees].
3. [Insert title of responsible person] will investigate the claim using [insert the name of your entity’s form and the location where it can be found] to determine root cause, and possible solutions for preventing recurrences. [Insert title of responsible person] will submit [insert the name of your entity’s form] to [insert name of ALL responsible persons] upon completion and no later than two weeks after notification of incident [this is a PennPRIME requirement and cannot be changed].
4.  [Insert title of responsible person] will review incident with [insert titles of ALL responsible persons/committees] to further determine root cause, and possible solutions for preventing recurrences. [Insert title of responsible person] will submit corrective actions to [insert titles of ALL responsible persons/committees].
5. [Insert title of responsible person] will track information using [insert your entity’s method of tracking. i.e. spreadsheet, writing info on report, etc.] noting all corrective actions, person responsible for completing actions and a due date. [Insert title of responsible person] will file all forms [insert location of hardcopy or electronic files].
6. [Insert title of responsible person] will check this spreadsheet monthly to insure corrective actions have been completed and follow-up with Department Heads as necessary. [Insert title of responsible person] will periodically review this spreadsheet and claims information to see if any trends exist, decide whether additional action is warranted, and contact PennPRIME for assistance, if needed.

Revised 10/20/17