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'0 <br />Accident Report FormAT R I; <br />I n e S o u r c e <br />A Vensure Employer Services Company <br />POST IN A CONSPICUOUS LOCATION <br />REPORT ALL ACCIDENTSANJURIES IMMEDIATELY! <br />Call MatrixOneSource at 866-453-2722 <br />All medical treatment beyond first aid must be preautorized by MatrixOneSource. <br />Client Companies must ensure that every injured employee submiys to a post accident drug screen at the <br />time of medical treatment. The employee's failure of refusal to submit a drug screwen could jepordize his/her <br />workers' compensation benefits. <br />1. First Aid - Get injured employee treatment by someone trained in first aid IMMEDIATELY! <br />2. Preauthorization and Treatment (When Employee is Not Severely Injured) - If more than first aid <br />is needed and the injured employee is not severely injured, notify MatrixOneSource immediately for <br />authorization and get the injured employee to the nearest medical clinic or facility for treatment and a <br />post -accident drug screen. <br />3. Emergency Treatment (When Employee is Severely injured) - If the injured employee is severely <br />injured, he/she should be taken to the nearest hospital for treatment and a post -accident drug screen <br />and Matrix OneSource should be notified immediately thereafter. IF YOU ARE NOT SURE IF AN <br />EMPLOYEE IS SEVERELY INJURED, TAKE THE EMPLOYEE TO THE NEAREST HOSPITAL FOR <br />EMERGENCY TREATMENT <br />4. Supervisor's Report of Accident - As soon as possible after the injured employee has been given <br />necessary medical treatment and submitted to a post -accident drug screen, his/her supervisor should <br />complete the Supervisor's Report of Accident form and forward it to MatrixOne Source (see information <br />below) within 24 hours of accident occurrence, Supervisors are responsible for obtaining statements from <br />any witnesses to the accident/injury and completing the Witness Report of Accident form. The form may <br />be obtained by calling MatrixOneSource or from the Matrix Source website at www.matrixonesource.com. <br />5. Employee's Report of Accident - The injured employee must complete an Employee's Report of Accident <br />form and forward it to MatrixOneSource (see information below) within 24 hours of accident occurrence. <br />If the injured employee is unable to complete the accident report due to injury, he/she should call <br />MatrixOneSource within the 24 hour time period (or as soon as possible) to discuss the accident. <br />Signature of Officer[Owner: W — <br />MOSFORM-FULLPEOENROLLMENT PACK <br />24 <br />Dale: 0310212022 <br />@2020 MatrixOneSource <br />