Work Injury Reporting

Protocol for Reporting Workers’ Compensation Accidents/Incidents
(For Staff members, employees, and volunteers only)

Please read the Protocol for Reporting Workers’ Compensation Accident/Incidents before completing the forms to report an injury.  Forward completed forms, via email to HRD@cityofhaverhill.com AND jennifer.schmidt@haverhill-ps.org, for processing.

If the injury occurs after the listed hours, the employee should go to the nearest emergency room.

If the injured occurs during normal work hours and the injury is not urgent but necessitates medical attention, all employees should be referred to one of the following locations for treatment of injuries that occur between the hours of 8 am – 8pm, Monday – Friday:

• AFC Urgent Care – Methuen location (380R Merrimack Street, 978-975-0700)
• AFC Urgent Care – North Andover location (129 Turnpike Street, 978-470-0800)
• MedExpress Urgent Care – Methuen location (2 Broadway, 978-688-4180)

You may also go to any location that accepts workers comp, please make sure they know it is a WC injury and have them contact City HR (HRD@cityofhaverhill.com or 978-374-2357) for billing information. If an injury is considered severe AND requires immediate attention, an ambulance may be called, or the employee can go to the nearest Emergency Room for medical attention. Follow up with one of the Urgent Care locations (see above) must take place.

Form 118

The Form 118 should be completed by someone other than the injured employee.  Complete the Form 118 if the employee is going to be out for less than 5 work days.  The Medical Authorization Form MUST be signed by the employee.

Form 101

The Form 101 should be completed by someone other than the injured employee.  Complete the Form 101 if the employee is going to be out for 5 or more work days.

Incident Report Form
The incident report should be completed when there is an incident involving a staff member and/or student.