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WC Form 1 – 2 revised 7/11/2023.
St. Louis P ubli c Sch o o ls E mp loye e /Sup e r visor Inju r y Rep o rt
Employee Statement (Printed and executed by Employee)
Scan Immediately to Human Resources at ERStaf[email protected]
EMPLOYEE INJURY REPORTING FORM
*EVERY BOX ON THIS PAGE MUST BE COMPLETED BY THE INJURED EMPLOYEE*
My signature indicates that I fully understand that any falsification of any injury may subject me to
disciplinary action, including termination of my employment with the St. Louis Public Schools.
Employee Signature ________________________________________________________ Date: _______________________________
Employee
Name: (Last, First, Middle)
Date of Birth
SSN
Position /Title
Home Address:
Home Phone:
Gender:
City / State/ Zip Code:
Alternate Phone:
Was time lost at work?
Yes No
Time work began:
Date of accident / injury
Time of Occurrence:
Location code of
employee:
School or Site location where incident occurred:
Specific area in the building:
Describe in detail how the injury occurred and what caused the injury to happen:
Describe the injury and parts of the body affected:
Name of Witnesses to Accident / Injury:
1.
2.
3.
Was the injury reported immediately to supervisor?
(If no explain failure to give notice):
Name of the person you first reported injury to and
date of report:
✓
Did the employee refuse the offer of Medical attention:
Yes No
If yes, reason for refusal:
✓
How was Employee transported to physician/clinic?
✓
Date received first medical treatment:
Who accompanied:
✓
Clinic: (Name of clinic, hospital or physician visited?)
Location:
2
WC Form 1 – 2 revised 7/11/2023.
Front
Back
EMPLOYEE AUTHORIZATION TO RELEASE MEDICAL RECORDS
I Hereby authorize
(Employee Signature) (Clinic/Hospital)
You are hereby authorized to release any information acquired in the course of my medical treatment to my employer
and CCMSI. Please forward immediately a Workers’ Compensation Report, a copy of this authorization and your
itemized billing statement to:
CCMSI ◆ 133 S. 11
th
Street ◆ St. Louis, MO 63102 ◆ (314) 231-4094
(ALL BILLING AND SPECIALTY REFERRALS ARE HANDLED BY CCMSI)
Initial medical treatment authorization to be completed by supervisor
You are hereby authorized to render necessary medical treatment to the above name employee of the St. Louis Public Schools. This
authorization is limited to the FIRST VISIT ONLY. Follow-up visits must be authorized by SLPS or CCMSI and must be scheduled
before or after work hours.
Supervisor Signature: Date:
Injured Body Part Chart (Typed and executed by Employee)
Please mark the
suspected area(s) of injury:
Name of body part(s) listed:
Employee Signature:
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WC Form 1 – 2 revised 7/11/2023.
St. L ouis P ubli c Sch o o ls E mploy e e /Sup e rvisor Inju r y Rep ort
Accident Investigation Report (Typed/Written and executed by Supervisor or Designee)
Scan Immediately to Human Resources at ERStaf[email protected]
Injured Employee’s Name:
Date of injury:
Supervisor’s Name:
Location:
Phone:
Supervisor’s Title:
Date Completing Report:
Please describe in detail how the injury occurred and what caused the injury to happen: To be completed by
supervisor (if not present describe what was reported to you.)
Describe how the injury occurred:
What if any events or conditions caused the accident: (i.e. wet floor, fight, standing on unstable surface, etc.):
Corrective action or plan to prevent reoccurrence:
Supervisor Signature: Date:
To be completed by Human resources only:
Hire Date:
Bi-Weekly Wages:
HR Contact:
Date Received:
School /Loc Type, Choose One:
Elem. Middle High Alt. Sch. Other
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WC Form 1 – 2 revised 7/11/2023.
St. L ouis P ubli c Sch o o ls E mploy e e /Sup e rvisor Inju r y Rep ort
Witness Statement(s) (Typed/Written and executed by Witness)
Scan Immediately to Human Resources at ERStaf[email protected]
Injured Employee’s Name:
Date of injury:
Witness Name:
Location:
Phone:
Supervisor’s Title:
Date Completing Report:
Please describe in detail how the injury occurred and what caused the injury to happen: To be completed by witness.
Describe how the injury occurred:
What if any events or conditions caused the accident: (i.e wet floor, fight, standing on unstable surface, etc.):
Corrective action or plan to prevent reoccurrence:
Witness Signature: Date:
Please print additional witness statements if necessary.
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WC Form 1 – 2 revised 7/11/2023.
Scan Immediately to Human Resources at [email protected]
WORKERS’ COMPENSATION REPORTING
GENERAL INSTRUCTIONS
INJURED EMPLOYEE:
Step 1: The employee is required to report any injury sustained during working hours or while on authorized St. Louis Public
Schools business to his/her immediate supervisor on the day the injury occurs and within 24 hours of the occurrence of
the accident/injury.
Step 2: The employee must complete the form WC1-2, St. Louis Public Schools Employee/Supervisor Injury Report, and submit
the form to the supervisor for signature. If medical treatment is required, the employee must obtain the supervisor’s
signature for authorization of medical treatment. The employee must make a copy of the report for the site
records and then take the original WC1-2 with him/her to the authorized medical provider Concentra. See
attached list of MEDICAL CENTER LOCATIONS.
Step 3: Immediately following the visit to an authorized doctor, the employee must provide his/her supervisor with the Work
Status Report from Concentra, either in person or by fax. The report should indicate that the employee was evaluated,
and a determination was made to either return to work for Regular Duty, return to work for Limited Duty with
Restrictions, or Unable to Work.
Step 4: Any medical charges incurred anywhere other than Concentra will not be covered under Workers’
Compensation and should be submitted to your group medical insurance carrier. The only exception to this rule
shall be the rare occasion when injury requires emergency treatment as deemed necessary in the best judgment
of the supervisor at the site of the injury.
PRINCIPAL/SUPERVISOR: DO NOT DELEGATE THIS RESPONSIBILITY TO OTHERS
Step 1: Provide the injured employee with an Employee/Supervisor Injury Report/Medical Treatment Authorization Form
(WC1-2). The employee will complete the majority of page (1) and all of page (2) of the forms, which is his/her account
of the accident/injury.
Step 2: Principal/supervisor will authorize treatment by signing the bottom of page 1, which authorizes the employee to obtain
medical treatment at a Concentra Medical Center. Additionally, the Supervisor shall complete and sign page 3 of the
form, which is the supervisor’s account of the accident/injury. The supervisor is not required to have firsthand
knowledge of the incident. When the Supervisor does not have firsthand knowledge, the report shall indicate what was
“alleged” to have happened.
Step 3: Scan Immediately to Human Resources at [email protected]rg OR Fax the completed WC1-2 immediately to Alysia
Palm at (314) 244-1739
Step 4: Retain a copy of the WC1-2 in a separate workers’ compensation file at the respective location.
Step 5: Code absences accordingly.
HUMAN RESOURCES DIVISION:
Step 1: When the Doctor’s Visit Summary Report indicates Unable to Work, the Human Resources Division will place the
employee on “Inactive Service – Workers Compensation Without Pay” until the employee is released for duty. The
first three (3) regularly scheduled workdays following the last day worked are not payable under the Missouri
Workers’ Compensation law, unless the employee will be absent more than 14 consecutive days, at which time
the first three days will be payable under workers’ compensation.
Step 2: The Human Resources Division will maintain the inactive service status until receipt of the physician’s statement
indicating that the employee is released for regular duty or limited duty with restrictions.
Step 3: For any Doctor’s Summary Report indicating “Limited Duty with Restrictions”, Human Resources Division will work
with the appropriate site administrator to evaluate limited duty opportunities and determine the appropriate course of
action. Each report will be evaluated on a case-by-case basis.
For question concerning this form, contact Employee Relations at 314-345-2218.
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WC Form 1 – 2 revised 7/11/2023.
Concentra Authorized Medical Facility Locations
Concentra Market St.
3100 Market Street
St. Louis, MO. 63103
(314) 421-2557
Fax: (314) 421-2046
Hours: M-F, 8 a.m.-5 p.m.
Concentra North Broadway
8340 North Broadway St.
St. Louis, MO. 63147
(314) 385-9563
Fax: (314) 385-9350
Hours: M-F, 8 a.m.-5 p.m.
Concentra Midtown
6542 Manchester
St. Louis, MO. 63139
(314) 647-0081
Fax : (314) 647-5485
Hours:
M-F, 8 a.m.-5 p.m.
Concentra Westport
83 Progress Parkway
Maryland Heights, MO. 63043
(314) 434-8174
Fax: (314) 434-8706
Hours:
M-F, 8 a.m.-5 p.m.
Concentra Hazelwood
463 Lynn Haven Lane
Hazelwood, MO. 63042
(314) 731-0448
Fax: (314) 731-0495
Hours: M-F, 8 a.m. – 5 p.m.
Concentra Fenton
128 Matrix Commons Drive
Fenton, MO 63026
(636) 349-6850
Fax: (636) 349-6641
Hours: M-F, 8 a.m.-5 p.m.
Concentra St. Charles
1794 Zumbehl Road
St. Charles, MO. 63303
(636) 947-1666
Fax: (636) 947-4185
Hours: M-F, 8:00 a.m. – 5 p.m.
24 HOUR EMERGENCY HOSPITALS (Only if an Emergency)
Barnes-Jewish Hospital
Emergency and Trauma Center
St. Louis, MO. 63110
400 S. Kingshighway Blvd.
(314) 362-9123
Saint Louis University Hospital
3635 Vista
St. Louis, MO 63110
(314) 577-8777
St. Mary’s Hospital
6420 Clayton Rd.
St. Louis, MO 63117
(314) 768-8360
