On-The-Job Injury Checklist

When an on-the-job injury occurs please follow the procedures listed below:

Determine level of treatment needed (no treatment, first aid only, or professional medical treatment).
Complete and forward the Universal Report Form to Human Resources within 24 hours via fax (433-8445) AND inter-office mail. This form must be signed by the employee, the preparer and a supervisor.


If the injury requires Professional Medical Treatment:

If an injury requiring professional medical treatment occurs notify Shannel Stults, Safety Coordinator, at 321 433-8449 or by email at sstults@cocoafl.org before you send the employee for treatment.

All non-urgent injuries must be sent to our Primary Care Physicians (MedFast Urgent Care or Atlantic Orthopedic Group). Injuries that are consider an emergency and require immediate medical attention should be sent to the participating urgent care center (Wuesthoff Hospital Emergency Room). Complete and provide the employee with the Treatment Authorization Form. Send a copy to Shannel Stults, Safety Coordinator. The employee must take the original form with them to the treating facility.


General, LIUNA, & Fire Employees:


If the injury requires professional medical treatment, the employee must be taken to have a urine test.

Police (PBA) Employees:

If the injury requires professional medical treatment AND the employee is found to be at fault for the accident/incident, the employee must be taken to have a urine and blood alcohol test.
You may use one of the authorized Wuesthoff Reference Laboratory draw stations. If none of the draw station locations are open at the time of the injury, you will need to take the employee to Wuesthoff Hospital in Rockledge for the drug screen. The employee must provide a chain of custody form to Wuesthoff prior to receiving the drug screen.


All Employees:

If an injury requiring professional medical treatment occurs notify Shannel Stults, Safety Coordinator, at 321 433-8449 or by email at sstults@cocoafl.org before you send the employee for treatment