Manager/Supervisor Responsibility

Injured Worker Declines Medical Treatment

• Supervisor's Report of Accident, S&T 202   - NCR Form
• Employee Request for Medical Treatment, S&T 201  - NCR Form

Step 1:
Upon notification of an injury or illness, a Manager or Supervisor must complete both a “Supervisor’s Report of Accident” ( S&T 202) form and an “Employee Request for Medical Treatment” ( S&T 201 ) form. The “Supervisor’s Report of Accident” ( S&T 202 ) form should:

• Include a detailed description of the accident
• Be completed within 24 hours of the accident

Step 2:
Offer the injured/illness worker immediate medical treatment

Step 3:
If the injured worker declines medical treatment the injured worker must sign and date the “Employee Request for Medical Treatment” ( S&T 201 ) indicating, “I have declined the offer of professional medical treatment at this time”

Step 4:
File the “Employee Request for Medical Treatment” ( S&T 201 ) form along with the “Supervisor’s Report of Accident” ( S&T 202 ) form in the departmental personnel file.

Step 5:
Inform the injured worker should they seek medical treatment at a later date, they are to inform their Manager/Supervisor immediately.