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WESTERN PUMP <br /> Petroleum & Lubrication Equipment Specialists <br /> • If possible , discuss the incident with the injured employee. Give the employee the Worker's <br /> Compensation Claim and Notice of Potential Eligibility form and explanation of benefits ifthey <br /> received injuries. Have them sign the form and fax a copy with the SIR. <br /> • Question other employees who may have witnessed the incident. <br /> • Take into consideration the following factors: <br /> o What was the employee doing just prior to and at the time of the incident? <br /> o Was this in pursuit of the employee's regular duties? <br /> o Was the employee properly instructed as to the manner in which to perform the duties? <br /> o Did the employee follow instructions? <br /> o Were other employees involved in the incident? <br /> o Was the equipment or machinery the employee was using in good condition ? <br /> o Was the equipment properly guarded? <br /> o Was the equipment suited for the purpose for which it was used? <br /> o Was the work area adequately lighted? <br /> o Were proper housekeeping conditions maintained ? <br /> o How was the same work done by other employees? <br /> o Is there a safer way in which the work could be accomplished ? <br /> o Was the employee in good health when reporting to work on the day of the accident? <br /> o If an unsafe condition was involved , determine what changes can be made to prevent a similar <br /> recurrence. <br /> • All investigation forms will be reviewed at the Safety Business Meeting to assure that a complete <br /> investigation has been made , incident cause determined and corrective action taken . <br /> Return to Work <br /> • After the injured employee has received medical treatment, he or she must return to the jobsite <br /> with a medical report from the treating physician , advising the Company of the employee's medical <br /> status. <br /> 3235 " F" Street, San Diego, CA 92102-3315 " 619-239-9988 Fax 619-239-9925 <br /> www. westernpump . com <br /> California Contractor's License #673853 <br /> California Certified Small Business #33547 <br />