You can download the PDF here.

Fill it in on your computer or print it out to complete and sign. Then:

  • Deliver to Lantzen Toomer in our Centerville office, or
  • Email to ltoomer@hoganconstruction.com.

OR

Fill in the form to the right (or below on narrow screens) and submit.

If you or a co-worker have a MINOR INJURY:

    1. Report the injury (yours or another person’s) to your Project Superintendent immediately.


    Notifying your supervisor of an injury one, two, or three days later is unacceptable.



    2. BEFORE going to a clinic, call Jared Morgan, 801-910-7011.

    3. Go to (or take the injured worker to) the clinic listed on the jobsite safety poster (in the job office), typically the nearest CONCENTRA CLINIC.

    4. Let the doctor know we have a MODIFIED DUTY PROGRAM available for injured employees. We will accommodate ANY light duty restrictions as long as the employee is not hospitalized.

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If you or a co-worker have a MAJOR INJURY:

If the injury is non-life-, limb-, or organ-threatening, you must go to the nearest Concentra. Going to a hospital ER for a non-life- or limb-threatening emergency is unacceptable.


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2. Call 911. Station people to direct the ambulance to the injured worker.

3. Notify the site Superintendent.

4. Contact Jared Morgan at 801-910-7011 immediately, but he does NOT need to approve an emergency room visit.

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Acknowledgment

My signature, below, indicates I have read and understand these instructions. I acknowledge I must attend the COMPANY-APPROVED clinic when needed, and only go to the emergency room with severe, life-, limb-, or organ-threatening injuries requiring more treatment than the company-approved clinic can likely provide.

Employee Name(Required)
MM slash DD slash YYYY
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