Accident Report (Employee)

Accident LocationPCEC

Districtportage

Supervisor NameJuan N/A

Date of Accident05/23/2022

Time of Accident05:00 PM

Employee NameMiyah Powell

Address6032 Applegrove Ln
Portage, MIchigan 49024
Map It

Phone(269) 290-5127

Date of Birth05/06/2003

Last 4 digits of your Social Security Number372295669

Do you think you need to see a doctor today?Not Sure

Description of Accident

I was in the restroom cleaning up vomit when I blacked out and I woke up on the floor and then vomited on the floor. My head has been throbbing since I woke up.

What part of your body has been injured? Check all that apply
  • Head

AuthorizationThis electronic signature is authorization for any and all Health Care Providers, including but limited to Hospitals, Clinics, Physician Offices, Diagnostic Centers and Therapy Facilities.

I , the undersigned, hereby authorize the Custodian of Records of health care providers to which this authorization has been directed to release any and all information which may be requested regarding myself and to photocopy any records regarding me, including records which have been maintained regarding my past or present physical or mental condition and treatment rendered, including but limited to my consumption of alcohol or use of drugs including those protected under Title 242 of the Code of Federal Regulations, Part 2; Psychological or Psychiatric records, including communications made by me to a social workers, psychologist or psychiatrist; including behavioral or mental health services.

All records for any and all dates of evaluation, care or treatment to be disclosed.

Make disclosure to: York, Risk Services Group, Inc. PO Box 620 Howell, MI 48844‐0620

The purpose and need for disclosure is: At the request of the undersigned to process the above reference claim.

As a claimant, I may revoke this authorization by notifying the Custodian of Records of applicable health care provider in writing of my desire to revoke it. However, I understand that any action already taken in reliance on this authorization cannot be reversed, and my revocation will not affect those actions.

This authorization expires one year from the date of execution.

A PHOTOCOPY OR DIGITALLY SHARED COPY OF THIS DOCUMENT SHALL BE CONSIDERED VALID AS IF THE ORIGINAL WERE OFFERED.

Electronic SignatureMiyah Powell

Date05/23/2022

Accident LocationHs

Districtcedar_springs

Supervisor NameReba Hulliberger

Date of Accident05/16/2022

Time of Accident06:00 PM

Employee NameReba Hulliberger

Address11871 newcosta Ave
Sand lake, Michigan 49343
Map It

Phone(616) 690-5493

Date of Birth01/10/1998

Last 4 digits of your Social Security Number1010

Do you think you need to see a doctor today?Not Sure

Description of Accident

Have a really heavy bag with the kitchen Joe knows about it and let the kitchen people know

What part of your body has been injured? Check all that apply
  • Upper Back
  • Middle Back
  • Lower Back

AuthorizationThis electronic signature is authorization for any and all Health Care Providers, including but limited to Hospitals, Clinics, Physician Offices, Diagnostic Centers and Therapy Facilities.

I , the undersigned, hereby authorize the Custodian of Records of health care providers to which this authorization has been directed to release any and all information which may be requested regarding myself and to photocopy any records regarding me, including records which have been maintained regarding my past or present physical or mental condition and treatment rendered, including but limited to my consumption of alcohol or use of drugs including those protected under Title 242 of the Code of Federal Regulations, Part 2; Psychological or Psychiatric records, including communications made by me to a social workers, psychologist or psychiatrist; including behavioral or mental health services.

All records for any and all dates of evaluation, care or treatment to be disclosed.

Make disclosure to: York, Risk Services Group, Inc. PO Box 620 Howell, MI 48844‐0620

The purpose and need for disclosure is: At the request of the undersigned to process the above reference claim.

As a claimant, I may revoke this authorization by notifying the Custodian of Records of applicable health care provider in writing of my desire to revoke it. However, I understand that any action already taken in reliance on this authorization cannot be reversed, and my revocation will not affect those actions.

This authorization expires one year from the date of execution.

A PHOTOCOPY OR DIGITALLY SHARED COPY OF THIS DOCUMENT SHALL BE CONSIDERED VALID AS IF THE ORIGINAL WERE OFFERED.

Electronic SignatureReba Hulliberger

Date05/16/2022

Accident LocationMoraine Elementary

Districtnorthville

Supervisor NameAngela Sisson

Date of Accident05/10/2022

Time of Accident07:15 AM

Employee NameShayia Thompson

Address9970 montrose
Detroit, MIchigan 48227
Map It

Phone(313) 808-9890

Date of Birth04/03/2001

Last 4 digits of your Social Security Number3591

Do you think you need to see a doctor today?Yes

Description of Accident

Injured back while going to sit down.

What part of your body has been injured? Check all that apply
  • Middle Back

AuthorizationThis electronic signature is authorization for any and all Health Care Providers, including but limited to Hospitals, Clinics, Physician Offices, Diagnostic Centers and Therapy Facilities.

I , the undersigned, hereby authorize the Custodian of Records of health care providers to which this authorization has been directed to release any and all information which may be requested regarding myself and to photocopy any records regarding me, including records which have been maintained regarding my past or present physical or mental condition and treatment rendered, including but limited to my consumption of alcohol or use of drugs including those protected under Title 242 of the Code of Federal Regulations, Part 2; Psychological or Psychiatric records, including communications made by me to a social workers, psychologist or psychiatrist; including behavioral or mental health services.

All records for any and all dates of evaluation, care or treatment to be disclosed.

Make disclosure to: York, Risk Services Group, Inc. PO Box 620 Howell, MI 48844‐0620

The purpose and need for disclosure is: At the request of the undersigned to process the above reference claim.

As a claimant, I may revoke this authorization by notifying the Custodian of Records of applicable health care provider in writing of my desire to revoke it. However, I understand that any action already taken in reliance on this authorization cannot be reversed, and my revocation will not affect those actions.

This authorization expires one year from the date of execution.

A PHOTOCOPY OR DIGITALLY SHARED COPY OF THIS DOCUMENT SHALL BE CONSIDERED VALID AS IF THE ORIGINAL WERE OFFERED.

Electronic SignatureShayia Thompson

Date05/10/2022

Accident Location1486

Districttri_county

Supervisor NameBonnie Paulsen

Date of Accident05/02/2022

Time of Accident05:55 PM

Employee Namebonnie paulsen

Address320 pine st
howard city, MIchigan 49329
Map It

Phone(616) 835-4345

Date of Birth03/18/1967

Last 4 digits of your Social Security Number7379

Do you think you need to see a doctor today?No

Description of Accident

Was pulling cart out of closet closet to Kitchen and scrapped left part of hand.

What part of your body has been injured? Check all that apply
  • Left Hand

AuthorizationThis electronic signature is authorization for any and all Health Care Providers, including but limited to Hospitals, Clinics, Physician Offices, Diagnostic Centers and Therapy Facilities.

I , the undersigned, hereby authorize the Custodian of Records of health care providers to which this authorization has been directed to release any and all information which may be requested regarding myself and to photocopy any records regarding me, including records which have been maintained regarding my past or present physical or mental condition and treatment rendered, including but limited to my consumption of alcohol or use of drugs including those protected under Title 242 of the Code of Federal Regulations, Part 2; Psychological or Psychiatric records, including communications made by me to a social workers, psychologist or psychiatrist; including behavioral or mental health services.

All records for any and all dates of evaluation, care or treatment to be disclosed.

Make disclosure to: York, Risk Services Group, Inc. PO Box 620 Howell, MI 48844‐0620

The purpose and need for disclosure is: At the request of the undersigned to process the above reference claim.

As a claimant, I may revoke this authorization by notifying the Custodian of Records of applicable health care provider in writing of my desire to revoke it. However, I understand that any action already taken in reliance on this authorization cannot be reversed, and my revocation will not affect those actions.

This authorization expires one year from the date of execution.

A PHOTOCOPY OR DIGITALLY SHARED COPY OF THIS DOCUMENT SHALL BE CONSIDERED VALID AS IF THE ORIGINAL WERE OFFERED.

Electronic Signaturebonnie paulsen

Date05/02/2022

Accident Location1486

Districttri_county

Supervisor NameLisa Johnson

Date of Accident05/02/2022

Time of Accident05:55 PM

Employee Namebonnie paulsen

Address320 pine st
howard city, MIchigan 49329
Map It

Phone(616) 835-4345

Date of Birth03/18/1967

Last 4 digits of your Social Security Number7379

Do you think you need to see a doctor today?No

Description of Accident

left top part of hand hit the door lock and scrapped it open.... have a bandage on the wound. Closet by kitchen.

What part of your body has been injured? Check all that apply
  • Left Hand

AuthorizationThis electronic signature is authorization for any and all Health Care Providers, including but limited to Hospitals, Clinics, Physician Offices, Diagnostic Centers and Therapy Facilities.

I , the undersigned, hereby authorize the Custodian of Records of health care providers to which this authorization has been directed to release any and all information which may be requested regarding myself and to photocopy any records regarding me, including records which have been maintained regarding my past or present physical or mental condition and treatment rendered, including but limited to my consumption of alcohol or use of drugs including those protected under Title 242 of the Code of Federal Regulations, Part 2; Psychological or Psychiatric records, including communications made by me to a social workers, psychologist or psychiatrist; including behavioral or mental health services.

All records for any and all dates of evaluation, care or treatment to be disclosed.

Make disclosure to: York, Risk Services Group, Inc. PO Box 620 Howell, MI 48844‐0620

The purpose and need for disclosure is: At the request of the undersigned to process the above reference claim.

As a claimant, I may revoke this authorization by notifying the Custodian of Records of applicable health care provider in writing of my desire to revoke it. However, I understand that any action already taken in reliance on this authorization cannot be reversed, and my revocation will not affect those actions.

This authorization expires one year from the date of execution.

A PHOTOCOPY OR DIGITALLY SHARED COPY OF THIS DOCUMENT SHALL BE CONSIDERED VALID AS IF THE ORIGINAL WERE OFFERED.

Electronic SignatureBonnie Paulsen

Date05/02/2022

Accident LocationMount Pleasant High School, next to Green Pod student entrance

Districtmount_pleasant

Supervisor NameSpike Lemmer

Date of Accident04/25/2022

Time of Accident10:00 AM

Employee NameCharles Gray

Address3700 E Deerfield Rd
Apt S1
Mount Pleasant, MIchigan 48858
Map It

Phone(989) 513-4831

Date of Birth03/19/1999

Last 4 digits of your Social Security Number0462

Do you think you need to see a doctor today?No

Description of Accident

I was on my knees scrubbing dog crap out of the carpet near the student entrance, and I pulled or strained a muscle in my right forearm. It was not serious, but I got some ice from the office, just in case.

What part of your body has been injured? Check all that apply
  • Right Wrist

AuthorizationThis electronic signature is authorization for any and all Health Care Providers, including but limited to Hospitals, Clinics, Physician Offices, Diagnostic Centers and Therapy Facilities.

I , the undersigned, hereby authorize the Custodian of Records of health care providers to which this authorization has been directed to release any and all information which may be requested regarding myself and to photocopy any records regarding me, including records which have been maintained regarding my past or present physical or mental condition and treatment rendered, including but limited to my consumption of alcohol or use of drugs including those protected under Title 242 of the Code of Federal Regulations, Part 2; Psychological or Psychiatric records, including communications made by me to a social workers, psychologist or psychiatrist; including behavioral or mental health services.

All records for any and all dates of evaluation, care or treatment to be disclosed.

Make disclosure to: York, Risk Services Group, Inc. PO Box 620 Howell, MI 48844‐0620

The purpose and need for disclosure is: At the request of the undersigned to process the above reference claim.

As a claimant, I may revoke this authorization by notifying the Custodian of Records of applicable health care provider in writing of my desire to revoke it. However, I understand that any action already taken in reliance on this authorization cannot be reversed, and my revocation will not affect those actions.

This authorization expires one year from the date of execution.

A PHOTOCOPY OR DIGITALLY SHARED COPY OF THIS DOCUMENT SHALL BE CONSIDERED VALID AS IF THE ORIGINAL WERE OFFERED.

Electronic SignatureCharles Gray

Date04/25/2022

Accident LocationCedar springs high school

Districtcedar_springs

Supervisor NameReba Hullibergrr

Date of Accident04/19/2022

Time of Accident08:00 PM

Employee NameAlex Pawloski

Address19525 W Pierson Rd
Pierson, MI 49339
Map It

Phone(231) 923-3721

Date of Birth12/18/1999

Last 4 digits of your Social Security Number5657

Do you think you need to see a doctor today?No

Description of Accident

As I was walking into a classroom my knee locked up, took the day off for rest.

What part of your body has been injured? Check all that apply
  • Left Knee

AuthorizationThis electronic signature is authorization for any and all Health Care Providers, including but limited to Hospitals, Clinics, Physician Offices, Diagnostic Centers and Therapy Facilities.

I , the undersigned, hereby authorize the Custodian of Records of health care providers to which this authorization has been directed to release any and all information which may be requested regarding myself and to photocopy any records regarding me, including records which have been maintained regarding my past or present physical or mental condition and treatment rendered, including but limited to my consumption of alcohol or use of drugs including those protected under Title 242 of the Code of Federal Regulations, Part 2; Psychological or Psychiatric records, including communications made by me to a social workers, psychologist or psychiatrist; including behavioral or mental health services.

All records for any and all dates of evaluation, care or treatment to be disclosed.

Make disclosure to: York, Risk Services Group, Inc. PO Box 620 Howell, MI 48844‐0620

The purpose and need for disclosure is: At the request of the undersigned to process the above reference claim.

As a claimant, I may revoke this authorization by notifying the Custodian of Records of applicable health care provider in writing of my desire to revoke it. However, I understand that any action already taken in reliance on this authorization cannot be reversed, and my revocation will not affect those actions.

This authorization expires one year from the date of execution.

A PHOTOCOPY OR DIGITALLY SHARED COPY OF THIS DOCUMENT SHALL BE CONSIDERED VALID AS IF THE ORIGINAL WERE OFFERED.

Electronic SignatureAlex Pawloski

Date04/20/2022

Accident LocationOutside on high school grounds

Districtoffice

Supervisor NameAyla Noah

Date of Accident04/14/2022

Time of Accident11:30 AM

Employee NameElizabeth Brace

Address326 miles st .
Lakeview, MIchigan 48850
Map It

Phone(616) 419-6835

Date of Birth12/19/1982

Last 4 digits of your Social Security Number7252

Do you think you need to see a doctor today?Yes

Description of Accident

She was riding her bike to the elementary. It was windy out and she lost her balance and fell. Her left side near chest it was was Injured.

What part of your body has been injured? Check all that apply
  • Upper Back
  • Left Shoulder

AuthorizationThis electronic signature is authorization for any and all Health Care Providers, including but limited to Hospitals, Clinics, Physician Offices, Diagnostic Centers and Therapy Facilities.

I , the undersigned, hereby authorize the Custodian of Records of health care providers to which this authorization has been directed to release any and all information which may be requested regarding myself and to photocopy any records regarding me, including records which have been maintained regarding my past or present physical or mental condition and treatment rendered, including but limited to my consumption of alcohol or use of drugs including those protected under Title 242 of the Code of Federal Regulations, Part 2; Psychological or Psychiatric records, including communications made by me to a social workers, psychologist or psychiatrist; including behavioral or mental health services.

All records for any and all dates of evaluation, care or treatment to be disclosed.

Make disclosure to: York, Risk Services Group, Inc. PO Box 620 Howell, MI 48844‐0620

The purpose and need for disclosure is: At the request of the undersigned to process the above reference claim.

As a claimant, I may revoke this authorization by notifying the Custodian of Records of applicable health care provider in writing of my desire to revoke it. However, I understand that any action already taken in reliance on this authorization cannot be reversed, and my revocation will not affect those actions.

This authorization expires one year from the date of execution.

A PHOTOCOPY OR DIGITALLY SHARED COPY OF THIS DOCUMENT SHALL BE CONSIDERED VALID AS IF THE ORIGINAL WERE OFFERED.

Electronic SignatureElizabeth Brace

Date04/14/2022

Accident LocationLater Elementary Paw Paw Mi

Districtvicksburg

Supervisor NameRobert Cheesman

Date of Accident04/08/2022

Time of Accident08:00 AM

Employee NameMichael Warn

Address419 N Miller St
Paw Paw, MIchigan 49079
Map It

Phone(616) 822-6393

Date of Birth08/29/1951

Last 4 digits of your Social Security Number4953

Do you think you need to see a doctor today?No

Description of Accident

Tried over the legs of a fan.
Fell fast first hitting the floor. Landed catching myself with my forearms, elbows, hands,knees, legs,and chest. Head is ok.

What part of your body has been injured? Check all that apply
  • Head
  • Left Wrist
  • Right Leg
  • Right Wrist
  • Left Knee
  • Left Hand
  • Right Knee
  • Left Leg
  • Left Foot
  • Right Foot

AuthorizationThis electronic signature is authorization for any and all Health Care Providers, including but limited to Hospitals, Clinics, Physician Offices, Diagnostic Centers and Therapy Facilities.

I , the undersigned, hereby authorize the Custodian of Records of health care providers to which this authorization has been directed to release any and all information which may be requested regarding myself and to photocopy any records regarding me, including records which have been maintained regarding my past or present physical or mental condition and treatment rendered, including but limited to my consumption of alcohol or use of drugs including those protected under Title 242 of the Code of Federal Regulations, Part 2; Psychological or Psychiatric records, including communications made by me to a social workers, psychologist or psychiatrist; including behavioral or mental health services.

All records for any and all dates of evaluation, care or treatment to be disclosed.

Make disclosure to: York, Risk Services Group, Inc. PO Box 620 Howell, MI 48844‐0620

The purpose and need for disclosure is: At the request of the undersigned to process the above reference claim.

As a claimant, I may revoke this authorization by notifying the Custodian of Records of applicable health care provider in writing of my desire to revoke it. However, I understand that any action already taken in reliance on this authorization cannot be reversed, and my revocation will not affect those actions.

This authorization expires one year from the date of execution.

A PHOTOCOPY OR DIGITALLY SHARED COPY OF THIS DOCUMENT SHALL BE CONSIDERED VALID AS IF THE ORIGINAL WERE OFFERED.

Electronic SignatureMichael Warn

Date04/08/2022

Accident LocationBTC Garden City

Districtgarden_city

Supervisor NameRonda Chavis

Date of Accident03/30/2022

Time of Accident06:00 PM

Employee NameCynthia Loesch

Address22111 Guidot st
Taylor, MIchigan 48180
Map It

Phone(734) 629-3282

Date of Birth08/06/1984

Last 4 digits of your Social Security Number7347

Do you think you need to see a doctor today?No

Description of Accident

I was getting ready to mop room 20 when I thought was a plastic piece on the floor and I got poked by a needle cap threw my glove and blood came threw.

AuthorizationThis electronic signature is authorization for any and all Health Care Providers, including but limited to Hospitals, Clinics, Physician Offices, Diagnostic Centers and Therapy Facilities.

I , the undersigned, hereby authorize the Custodian of Records of health care providers to which this authorization has been directed to release any and all information which may be requested regarding myself and to photocopy any records regarding me, including records which have been maintained regarding my past or present physical or mental condition and treatment rendered, including but limited to my consumption of alcohol or use of drugs including those protected under Title 242 of the Code of Federal Regulations, Part 2; Psychological or Psychiatric records, including communications made by me to a social workers, psychologist or psychiatrist; including behavioral or mental health services.

All records for any and all dates of evaluation, care or treatment to be disclosed.

Make disclosure to: York, Risk Services Group, Inc. PO Box 620 Howell, MI 48844‐0620

The purpose and need for disclosure is: At the request of the undersigned to process the above reference claim.

As a claimant, I may revoke this authorization by notifying the Custodian of Records of applicable health care provider in writing of my desire to revoke it. However, I understand that any action already taken in reliance on this authorization cannot be reversed, and my revocation will not affect those actions.

This authorization expires one year from the date of execution.

A PHOTOCOPY OR DIGITALLY SHARED COPY OF THIS DOCUMENT SHALL BE CONSIDERED VALID AS IF THE ORIGINAL WERE OFFERED.

Electronic SignatureCynthia Loesch

Date03/30/2022

Accident LocationIonia high school gym

Districtionia

Supervisor NameCindy Lake

Date of Accident03/26/2022

Time of Accident03:00 PM

Employee NameDavid Wieczorek

Address828 e Washington
Ionia, MIchigan 48846
Map It

Phone(616) 706-1560

Date of Birth04/04/1953

Last 4 digits of your Social Security Number8669

Do you think you need to see a doctor today?No

Description of Accident

Trip while group was rolling up tarp

What part of your body has been injured? Check all that apply
  • Left Wrist
  • Left Knee
  • Lower Back
  • Right Knee

AuthorizationThis electronic signature is authorization for any and all Health Care Providers, including but limited to Hospitals, Clinics, Physician Offices, Diagnostic Centers and Therapy Facilities.

I , the undersigned, hereby authorize the Custodian of Records of health care providers to which this authorization has been directed to release any and all information which may be requested regarding myself and to photocopy any records regarding me, including records which have been maintained regarding my past or present physical or mental condition and treatment rendered, including but limited to my consumption of alcohol or use of drugs including those protected under Title 242 of the Code of Federal Regulations, Part 2; Psychological or Psychiatric records, including communications made by me to a social workers, psychologist or psychiatrist; including behavioral or mental health services.

All records for any and all dates of evaluation, care or treatment to be disclosed.

Make disclosure to: York, Risk Services Group, Inc. PO Box 620 Howell, MI 48844‐0620

The purpose and need for disclosure is: At the request of the undersigned to process the above reference claim.

As a claimant, I may revoke this authorization by notifying the Custodian of Records of applicable health care provider in writing of my desire to revoke it. However, I understand that any action already taken in reliance on this authorization cannot be reversed, and my revocation will not affect those actions.

This authorization expires one year from the date of execution.

A PHOTOCOPY OR DIGITALLY SHARED COPY OF THIS DOCUMENT SHALL BE CONSIDERED VALID AS IF THE ORIGINAL WERE OFFERED.

Electronic SignatureDavid Wieczorek

Date03/28/2022

Accident Locationbyron center highschool

Districtbyron_center

Supervisor Namejoe maher

Date of Accident03/28/2022

Time of Accident01:20 PM

Employee NameHannah Hudgens

Address2663 woodlake ct sw apt 1
Wyoming, MI 49519
Map It

Phone(616) 690-9281

Date of Birth10/05/1990

Last 4 digits of your Social Security Number8490

Do you think you need to see a doctor today?Not Sure

Description of Accident

was moving a table and had momentum going and slammed the side of my hand into another table .
instant swelling and pain plus cut lines.

right hand( there’s no right hand box to check )

What part of your body has been injured? Check all that apply
  • Right Wrist

AuthorizationThis electronic signature is authorization for any and all Health Care Providers, including but limited to Hospitals, Clinics, Physician Offices, Diagnostic Centers and Therapy Facilities.

I , the undersigned, hereby authorize the Custodian of Records of health care providers to which this authorization has been directed to release any and all information which may be requested regarding myself and to photocopy any records regarding me, including records which have been maintained regarding my past or present physical or mental condition and treatment rendered, including but limited to my consumption of alcohol or use of drugs including those protected under Title 242 of the Code of Federal Regulations, Part 2; Psychological or Psychiatric records, including communications made by me to a social workers, psychologist or psychiatrist; including behavioral or mental health services.

All records for any and all dates of evaluation, care or treatment to be disclosed.

Make disclosure to: York, Risk Services Group, Inc. PO Box 620 Howell, MI 48844‐0620

The purpose and need for disclosure is: At the request of the undersigned to process the above reference claim.

As a claimant, I may revoke this authorization by notifying the Custodian of Records of applicable health care provider in writing of my desire to revoke it. However, I understand that any action already taken in reliance on this authorization cannot be reversed, and my revocation will not affect those actions.

This authorization expires one year from the date of execution.

A PHOTOCOPY OR DIGITALLY SHARED COPY OF THIS DOCUMENT SHALL BE CONSIDERED VALID AS IF THE ORIGINAL WERE OFFERED.

Electronic SignatureHannah Hudgens

Date03/28/2022

Accident LocationBrown Elementary

Districtbyron_center

Supervisor NameJolene Moore

Date of Accident03/24/2022

Time of Accident11:30 PM

Employee NameSeayereanah Carey

Address2107 Huizenga Ave sw
Wyoming, Michigan 49509
Map It

Phone(616) 855-4333

Date of Birth06/22/1998

Last 4 digits of your Social Security Number2565

Do you think you need to see a doctor today?Not Sure

Description of Accident

Went to go into my closest to grab the extra spray bottle and forgot I set my putty knife on the shelf. It caught me just right and cut me. I got the bleeding to stop but It burns and it hurts.
On my left ARM

What part of your body has been injured? Check all that apply
  • Left Wrist

AuthorizationThis electronic signature is authorization for any and all Health Care Providers, including but limited to Hospitals, Clinics, Physician Offices, Diagnostic Centers and Therapy Facilities.

I , the undersigned, hereby authorize the Custodian of Records of health care providers to which this authorization has been directed to release any and all information which may be requested regarding myself and to photocopy any records regarding me, including records which have been maintained regarding my past or present physical or mental condition and treatment rendered, including but limited to my consumption of alcohol or use of drugs including those protected under Title 242 of the Code of Federal Regulations, Part 2; Psychological or Psychiatric records, including communications made by me to a social workers, psychologist or psychiatrist; including behavioral or mental health services.

All records for any and all dates of evaluation, care or treatment to be disclosed.

Make disclosure to: York, Risk Services Group, Inc. PO Box 620 Howell, MI 48844‐0620

The purpose and need for disclosure is: At the request of the undersigned to process the above reference claim.

As a claimant, I may revoke this authorization by notifying the Custodian of Records of applicable health care provider in writing of my desire to revoke it. However, I understand that any action already taken in reliance on this authorization cannot be reversed, and my revocation will not affect those actions.

This authorization expires one year from the date of execution.

A PHOTOCOPY OR DIGITALLY SHARED COPY OF THIS DOCUMENT SHALL BE CONSIDERED VALID AS IF THE ORIGINAL WERE OFFERED.

Electronic SignatureSeayereanah Carey

Date03/23/2022

Accident LocationLakeview middle school

Districtlakeview

Supervisor NameTracy Miles

Date of Accident03/23/2022

Time of Accident08:49 PM

Employee NameJessica West

Address11338 Backus Rx
Lakeview, MIchigan 48850
Map It

Phone(616) 835-6207

Date of Birth01/23/1995

Last 4 digits of your Social Security Number6610

Do you think you need to see a doctor today?No

Description of Accident

Pinched pinky finger on left hand between the gym doors and the stupid scrubber

What part of your body has been injured? Check all that apply
  • Left Hand

AuthorizationThis electronic signature is authorization for any and all Health Care Providers, including but limited to Hospitals, Clinics, Physician Offices, Diagnostic Centers and Therapy Facilities.

I , the undersigned, hereby authorize the Custodian of Records of health care providers to which this authorization has been directed to release any and all information which may be requested regarding myself and to photocopy any records regarding me, including records which have been maintained regarding my past or present physical or mental condition and treatment rendered, including but limited to my consumption of alcohol or use of drugs including those protected under Title 242 of the Code of Federal Regulations, Part 2; Psychological or Psychiatric records, including communications made by me to a social workers, psychologist or psychiatrist; including behavioral or mental health services.

All records for any and all dates of evaluation, care or treatment to be disclosed.

Make disclosure to: York, Risk Services Group, Inc. PO Box 620 Howell, MI 48844‐0620

The purpose and need for disclosure is: At the request of the undersigned to process the above reference claim.

As a claimant, I may revoke this authorization by notifying the Custodian of Records of applicable health care provider in writing of my desire to revoke it. However, I understand that any action already taken in reliance on this authorization cannot be reversed, and my revocation will not affect those actions.

This authorization expires one year from the date of execution.

A PHOTOCOPY OR DIGITALLY SHARED COPY OF THIS DOCUMENT SHALL BE CONSIDERED VALID AS IF THE ORIGINAL WERE OFFERED.

Electronic SignatureJessica West

Date03/23/2022

Accident LocationNorthville,Michigan

Supervisor NameAntoine Dixon

Date of Accident03/22/2022

Time of Accident09:30 PM

Employee NameDaniel Davis

Address19801 Silver Springs
Northville, MIchigan 48167
Map It

Phone(248) 345-9652

Date of Birth09/10/1964

Last 4 digits of your Social Security Number7759

Do you think you need to see a doctor today?Not Sure

Description of Accident

Lifting and moving school science kits. The lufting i think has caused a hernia on the left side groin area

AuthorizationThis electronic signature is authorization for any and all Health Care Providers, including but limited to Hospitals, Clinics, Physician Offices, Diagnostic Centers and Therapy Facilities.

I , the undersigned, hereby authorize the Custodian of Records of health care providers to which this authorization has been directed to release any and all information which may be requested regarding myself and to photocopy any records regarding me, including records which have been maintained regarding my past or present physical or mental condition and treatment rendered, including but limited to my consumption of alcohol or use of drugs including those protected under Title 242 of the Code of Federal Regulations, Part 2; Psychological or Psychiatric records, including communications made by me to a social workers, psychologist or psychiatrist; including behavioral or mental health services.

All records for any and all dates of evaluation, care or treatment to be disclosed.

Make disclosure to: York, Risk Services Group, Inc. PO Box 620 Howell, MI 48844‐0620

The purpose and need for disclosure is: At the request of the undersigned to process the above reference claim.

As a claimant, I may revoke this authorization by notifying the Custodian of Records of applicable health care provider in writing of my desire to revoke it. However, I understand that any action already taken in reliance on this authorization cannot be reversed, and my revocation will not affect those actions.

This authorization expires one year from the date of execution.

A PHOTOCOPY OR DIGITALLY SHARED COPY OF THIS DOCUMENT SHALL BE CONSIDERED VALID AS IF THE ORIGINAL WERE OFFERED.

Electronic SignatureDaniel Davis

Date03/23/2022

Accident LocationMidland

Districtnorth_banks

Supervisor NameJessica Bowen

Date of Accident03/14/2022

Time of Accident06:00 PM

Employee NameKathy Owens

Address1407 E Wheeler St
Midland, MIchigan 48642
Map It

Phone(989) 615-8324

Date of Birth12/17/1956

Last 4 digits of your Social Security Number8746

Do you think you need to see a doctor today?Not Sure

Description of Accident

Chemical exposure. Intolerant to fumes from cleaning agent.

What part of your body has been injured? Check all that apply
  • Head
  • Mouth

AuthorizationThis electronic signature is authorization for any and all Health Care Providers, including but limited to Hospitals, Clinics, Physician Offices, Diagnostic Centers and Therapy Facilities.

I , the undersigned, hereby authorize the Custodian of Records of health care providers to which this authorization has been directed to release any and all information which may be requested regarding myself and to photocopy any records regarding me, including records which have been maintained regarding my past or present physical or mental condition and treatment rendered, including but limited to my consumption of alcohol or use of drugs including those protected under Title 242 of the Code of Federal Regulations, Part 2; Psychological or Psychiatric records, including communications made by me to a social workers, psychologist or psychiatrist; including behavioral or mental health services.

All records for any and all dates of evaluation, care or treatment to be disclosed.

Make disclosure to: York, Risk Services Group, Inc. PO Box 620 Howell, MI 48844‐0620

The purpose and need for disclosure is: At the request of the undersigned to process the above reference claim.

As a claimant, I may revoke this authorization by notifying the Custodian of Records of applicable health care provider in writing of my desire to revoke it. However, I understand that any action already taken in reliance on this authorization cannot be reversed, and my revocation will not affect those actions.

This authorization expires one year from the date of execution.

A PHOTOCOPY OR DIGITALLY SHARED COPY OF THIS DOCUMENT SHALL BE CONSIDERED VALID AS IF THE ORIGINAL WERE OFFERED.

Electronic SignatureKathy Owens

Date03/23/2022

Accident LocationByron center high-school

Districtbyron_center

Supervisor NameJoe Maher

Date of Accident03/15/2022

Time of Accident12:40 AM

Employee NameJolene Moore

Address950 Denver Hertog
Wyoming, Michigan 49509
Map It

Phone(616) 893-7876

Date of Birth09/01/1977

Last 4 digits of your Social Security Number2966

Do you think you need to see a doctor today?Yes

Description of Accident

Cut on my head
From shelf by the sink in kitchen at Byron high school

What part of your body has been injured? Check all that apply
  • Head

AuthorizationThis electronic signature is authorization for any and all Health Care Providers, including but limited to Hospitals, Clinics, Physician Offices, Diagnostic Centers and Therapy Facilities.

I , the undersigned, hereby authorize the Custodian of Records of health care providers to which this authorization has been directed to release any and all information which may be requested regarding myself and to photocopy any records regarding me, including records which have been maintained regarding my past or present physical or mental condition and treatment rendered, including but limited to my consumption of alcohol or use of drugs including those protected under Title 242 of the Code of Federal Regulations, Part 2; Psychological or Psychiatric records, including communications made by me to a social workers, psychologist or psychiatrist; including behavioral or mental health services.

All records for any and all dates of evaluation, care or treatment to be disclosed.

Make disclosure to: York, Risk Services Group, Inc. PO Box 620 Howell, MI 48844‐0620

The purpose and need for disclosure is: At the request of the undersigned to process the above reference claim.

As a claimant, I may revoke this authorization by notifying the Custodian of Records of applicable health care provider in writing of my desire to revoke it. However, I understand that any action already taken in reliance on this authorization cannot be reversed, and my revocation will not affect those actions.

This authorization expires one year from the date of execution.

A PHOTOCOPY OR DIGITALLY SHARED COPY OF THIS DOCUMENT SHALL BE CONSIDERED VALID AS IF THE ORIGINAL WERE OFFERED.

Electronic SignatureJolene Moore

Date03/15/2022

Accident LocationHs

Districtcedar_springs

Supervisor NameReba Hulliberger

Date of Accident03/11/2022

Time of Accident06:00 PM

Employee NameReba Hulliberger

Address11871 S Newcosta Ave
Sand Lake, Michigan 49343-9604
Map It

Phone(616) 690-5493

Date of Birth01/10/1998

Last 4 digits of your Social Security Number1010

Do you think you need to see a doctor today?Not Sure

Description of Accident

I vacuum all the hs on friday my Wrist hurt a little on bit on friday so i like maybe do to just vacuuming alot and rest it over the weekend be better on monday but still hurts and brothers me more now then did on friday

What part of your body has been injured? Check all that apply
  • Left Wrist

AuthorizationThis electronic signature is authorization for any and all Health Care Providers, including but limited to Hospitals, Clinics, Physician Offices, Diagnostic Centers and Therapy Facilities.

I , the undersigned, hereby authorize the Custodian of Records of health care providers to which this authorization has been directed to release any and all information which may be requested regarding myself and to photocopy any records regarding me, including records which have been maintained regarding my past or present physical or mental condition and treatment rendered, including but limited to my consumption of alcohol or use of drugs including those protected under Title 242 of the Code of Federal Regulations, Part 2; Psychological or Psychiatric records, including communications made by me to a social workers, psychologist or psychiatrist; including behavioral or mental health services.

All records for any and all dates of evaluation, care or treatment to be disclosed.

Make disclosure to: York, Risk Services Group, Inc. PO Box 620 Howell, MI 48844‐0620

The purpose and need for disclosure is: At the request of the undersigned to process the above reference claim.

As a claimant, I may revoke this authorization by notifying the Custodian of Records of applicable health care provider in writing of my desire to revoke it. However, I understand that any action already taken in reliance on this authorization cannot be reversed, and my revocation will not affect those actions.

This authorization expires one year from the date of execution.

A PHOTOCOPY OR DIGITALLY SHARED COPY OF THIS DOCUMENT SHALL BE CONSIDERED VALID AS IF THE ORIGINAL WERE OFFERED.

Electronic SignatureReba Hulliberger

Date03/14/2022

Accident LocationSmithfield

Districtoffice

Supervisor NameAyla Noah

Date of Accident02/11/2022

Time of Accident05:30 PM

Employee NameDavid Rodriguez

Address4462 Hyde Park Ave. SW
Wyoming, Michigan 49548
Map It

Phone(616) 322-5700

Date of Birth10/28/1956

Last 4 digits of your Social Security Number2577

Do you think you need to see a doctor today?Yes

Description of Accident

Passed out and fell flat on floor. chipped tooth

What part of your body has been injured? Check all that apply
  • Teeth

AuthorizationThis electronic signature is authorization for any and all Health Care Providers, including but limited to Hospitals, Clinics, Physician Offices, Diagnostic Centers and Therapy Facilities.

I , the undersigned, hereby authorize the Custodian of Records of health care providers to which this authorization has been directed to release any and all information which may be requested regarding myself and to photocopy any records regarding me, including records which have been maintained regarding my past or present physical or mental condition and treatment rendered, including but limited to my consumption of alcohol or use of drugs including those protected under Title 242 of the Code of Federal Regulations, Part 2; Psychological or Psychiatric records, including communications made by me to a social workers, psychologist or psychiatrist; including behavioral or mental health services.

All records for any and all dates of evaluation, care or treatment to be disclosed.

Make disclosure to: York, Risk Services Group, Inc. PO Box 620 Howell, MI 48844‐0620

The purpose and need for disclosure is: At the request of the undersigned to process the above reference claim.

As a claimant, I may revoke this authorization by notifying the Custodian of Records of applicable health care provider in writing of my desire to revoke it. However, I understand that any action already taken in reliance on this authorization cannot be reversed, and my revocation will not affect those actions.

This authorization expires one year from the date of execution.

A PHOTOCOPY OR DIGITALLY SHARED COPY OF THIS DOCUMENT SHALL BE CONSIDERED VALID AS IF THE ORIGINAL WERE OFFERED.

Electronic SignatureDavid Rodriguez

Date03/09/2022

Accident LocationNorth Ohio

Districtoffice

Supervisor NameJessica Petty

Date of Accident03/07/2022

Time of Accident07:20 AM

Employee NameMark Church

Address633 rosemary st
Gaylord, MIchigan 49736
Map It

Phone(517) 983-8102

Date of Birth01/11/1961

Last 4 digits of your Social Security Number7653

Do you think you need to see a doctor today?Not Sure

Description of Accident

Fell on sice on side walk. Just walking down the sidewalk. Fell on bucket while carrying it so Fell on his chest

AuthorizationThis electronic signature is authorization for any and all Health Care Providers, including but limited to Hospitals, Clinics, Physician Offices, Diagnostic Centers and Therapy Facilities.

I , the undersigned, hereby authorize the Custodian of Records of health care providers to which this authorization has been directed to release any and all information which may be requested regarding myself and to photocopy any records regarding me, including records which have been maintained regarding my past or present physical or mental condition and treatment rendered, including but limited to my consumption of alcohol or use of drugs including those protected under Title 242 of the Code of Federal Regulations, Part 2; Psychological or Psychiatric records, including communications made by me to a social workers, psychologist or psychiatrist; including behavioral or mental health services.

All records for any and all dates of evaluation, care or treatment to be disclosed.

Make disclosure to: York, Risk Services Group, Inc. PO Box 620 Howell, MI 48844‐0620

The purpose and need for disclosure is: At the request of the undersigned to process the above reference claim.

As a claimant, I may revoke this authorization by notifying the Custodian of Records of applicable health care provider in writing of my desire to revoke it. However, I understand that any action already taken in reliance on this authorization cannot be reversed, and my revocation will not affect those actions.

This authorization expires one year from the date of execution.

A PHOTOCOPY OR DIGITALLY SHARED COPY OF THIS DOCUMENT SHALL BE CONSIDERED VALID AS IF THE ORIGINAL WERE OFFERED.

Electronic SignatureJessica Bowen

Date03/07/2022

Accident LocationGrand Rapids Office

Districtoffice

Supervisor NameDarla Bloom

Date of Accident03/03/2022

Time of Accident04:30 PM

Employee NameGregory Schramm

Address5140 Pinnacle DR SW
Wyoming, MI 49519
Map It

Phone(616) 405-5161

Date of Birth06/29/1991

Last 4 digits of your Social Security Number7487

Do you think you need to see a doctor today?No

Description of Accident

While moving a stack of chairs in the training room, I twisted my right wrist. No immediate pain after, but there is pain in certain ranges of motion when I resumed moving items around the room. It is feeling better, just slightly sore at this point.

What part of your body has been injured? Check all that apply
  • Right Wrist

AuthorizationThis electronic signature is authorization for any and all Health Care Providers, including but limited to Hospitals, Clinics, Physician Offices, Diagnostic Centers and Therapy Facilities.

I , the undersigned, hereby authorize the Custodian of Records of health care providers to which this authorization has been directed to release any and all information which may be requested regarding myself and to photocopy any records regarding me, including records which have been maintained regarding my past or present physical or mental condition and treatment rendered, including but limited to my consumption of alcohol or use of drugs including those protected under Title 242 of the Code of Federal Regulations, Part 2; Psychological or Psychiatric records, including communications made by me to a social workers, psychologist or psychiatrist; including behavioral or mental health services.

All records for any and all dates of evaluation, care or treatment to be disclosed.

Make disclosure to: York, Risk Services Group, Inc. PO Box 620 Howell, MI 48844‐0620

The purpose and need for disclosure is: At the request of the undersigned to process the above reference claim.

As a claimant, I may revoke this authorization by notifying the Custodian of Records of applicable health care provider in writing of my desire to revoke it. However, I understand that any action already taken in reliance on this authorization cannot be reversed, and my revocation will not affect those actions.

This authorization expires one year from the date of execution.

A PHOTOCOPY OR DIGITALLY SHARED COPY OF THIS DOCUMENT SHALL BE CONSIDERED VALID AS IF THE ORIGINAL WERE OFFERED.

Electronic SignatureGregory Schramm

Date03/03/2022

Accident LocationEdgerton

Districttri_county

Supervisor NameLisa Johnson

Date of Accident02/24/2022

Time of Accident10:32 PM

Employee NameBarbara Powell

AddressMIchigan
Map It

Phone(231) 519-6768

Date of Birth10/10/1996

Last 4 digits of your Social Security Number8626

Do you think you need to see a doctor today?No

Description of Accident

Slipped on ice on outside stairs

What part of your body has been injured? Check all that apply
  • Middle Back

AuthorizationThis electronic signature is authorization for any and all Health Care Providers, including but limited to Hospitals, Clinics, Physician Offices, Diagnostic Centers and Therapy Facilities.

I , the undersigned, hereby authorize the Custodian of Records of health care providers to which this authorization has been directed to release any and all information which may be requested regarding myself and to photocopy any records regarding me, including records which have been maintained regarding my past or present physical or mental condition and treatment rendered, including but limited to my consumption of alcohol or use of drugs including those protected under Title 242 of the Code of Federal Regulations, Part 2; Psychological or Psychiatric records, including communications made by me to a social workers, psychologist or psychiatrist; including behavioral or mental health services.

All records for any and all dates of evaluation, care or treatment to be disclosed.

Make disclosure to: York, Risk Services Group, Inc. PO Box 620 Howell, MI 48844‐0620

The purpose and need for disclosure is: At the request of the undersigned to process the above reference claim.

As a claimant, I may revoke this authorization by notifying the Custodian of Records of applicable health care provider in writing of my desire to revoke it. However, I understand that any action already taken in reliance on this authorization cannot be reversed, and my revocation will not affect those actions.

This authorization expires one year from the date of execution.

A PHOTOCOPY OR DIGITALLY SHARED COPY OF THIS DOCUMENT SHALL BE CONSIDERED VALID AS IF THE ORIGINAL WERE OFFERED.

Electronic SignatureBarbara Powell

Date02/25/2022

Accident LocationAt Middle school dumpsters

Districtreed_city

Supervisor NameRocky Mims

Date of Accident02/24/2022

Time of Accident08:40 PM

Employee NameJessica Garrow

Address14983 200th ave
Leroy, MIchigan 49655
Map It

Phone(231) 468-8999

Date of Birth12/26/1979

Last 4 digits of your Social Security Number1539

Do you think you need to see a doctor today?No

Description of Accident

Walked in front of far dumpster and slipped on the ice

What part of your body has been injured? Check all that apply
  • Head
  • Right Leg
  • Right Wrist
  • Right Ankle
  • Right Foot

AuthorizationThis electronic signature is authorization for any and all Health Care Providers, including but limited to Hospitals, Clinics, Physician Offices, Diagnostic Centers and Therapy Facilities.

I , the undersigned, hereby authorize the Custodian of Records of health care providers to which this authorization has been directed to release any and all information which may be requested regarding myself and to photocopy any records regarding me, including records which have been maintained regarding my past or present physical or mental condition and treatment rendered, including but limited to my consumption of alcohol or use of drugs including those protected under Title 242 of the Code of Federal Regulations, Part 2; Psychological or Psychiatric records, including communications made by me to a social workers, psychologist or psychiatrist; including behavioral or mental health services.

All records for any and all dates of evaluation, care or treatment to be disclosed.

Make disclosure to: York, Risk Services Group, Inc. PO Box 620 Howell, MI 48844‐0620

The purpose and need for disclosure is: At the request of the undersigned to process the above reference claim.

As a claimant, I may revoke this authorization by notifying the Custodian of Records of applicable health care provider in writing of my desire to revoke it. However, I understand that any action already taken in reliance on this authorization cannot be reversed, and my revocation will not affect those actions.

This authorization expires one year from the date of execution.

A PHOTOCOPY OR DIGITALLY SHARED COPY OF THIS DOCUMENT SHALL BE CONSIDERED VALID AS IF THE ORIGINAL WERE OFFERED.

Electronic SignatureJessica Garrow

Date02/24/2022

Accident LocationSparta Middle School weight room

Districtsparta

Supervisor NameJodi Hawley-Jack

Date of Accident02/22/2022

Time of Accident07:40 PM

Employee NameJoHanna King

Address4908 McClelland Ave
Grant, MIchigan 49327
Map It

Phone(231) 349-4853

Date of Birth11/08/2000

Last 4 digits of your Social Security Number0000

Do you think you need to see a doctor today?Yes

Description of Accident

Bumped head on equipment while cleaning weight room.

What part of your body has been injured? Check all that apply
  • Head

AuthorizationThis electronic signature is authorization for any and all Health Care Providers, including but limited to Hospitals, Clinics, Physician Offices, Diagnostic Centers and Therapy Facilities.

I , the undersigned, hereby authorize the Custodian of Records of health care providers to which this authorization has been directed to release any and all information which may be requested regarding myself and to photocopy any records regarding me, including records which have been maintained regarding my past or present physical or mental condition and treatment rendered, including but limited to my consumption of alcohol or use of drugs including those protected under Title 242 of the Code of Federal Regulations, Part 2; Psychological or Psychiatric records, including communications made by me to a social workers, psychologist or psychiatrist; including behavioral or mental health services.

All records for any and all dates of evaluation, care or treatment to be disclosed.

Make disclosure to: York, Risk Services Group, Inc. PO Box 620 Howell, MI 48844‐0620

The purpose and need for disclosure is: At the request of the undersigned to process the above reference claim.

As a claimant, I may revoke this authorization by notifying the Custodian of Records of applicable health care provider in writing of my desire to revoke it. However, I understand that any action already taken in reliance on this authorization cannot be reversed, and my revocation will not affect those actions.

This authorization expires one year from the date of execution.

A PHOTOCOPY OR DIGITALLY SHARED COPY OF THIS DOCUMENT SHALL BE CONSIDERED VALID AS IF THE ORIGINAL WERE OFFERED.

Electronic SignatureJoHanna King

Date02/22/2022

Accident LocationDewitt Scott School

Districtdewitt

Supervisor NameElizabeth Wocjik

Date of Accident02/21/2022

Time of Accident08:45 AM

Employee NameBethany Pickens

AddressMIchigan
Map It

Phone(517) 285-5280

Date of Birth11/13/1990

Last 4 digits of your Social Security Number7828

Do you think you need to see a doctor today?No

Description of Accident

I went to my vehicle to get my coffee. On the handicap sidewalk, it was all ice. I slipped and fell. immediately after, I salted the slippery area.

What part of your body has been injured? Check all that apply
  • Head
  • Upper Back
  • Left Foot

AuthorizationThis electronic signature is authorization for any and all Health Care Providers, including but limited to Hospitals, Clinics, Physician Offices, Diagnostic Centers and Therapy Facilities.

I , the undersigned, hereby authorize the Custodian of Records of health care providers to which this authorization has been directed to release any and all information which may be requested regarding myself and to photocopy any records regarding me, including records which have been maintained regarding my past or present physical or mental condition and treatment rendered, including but limited to my consumption of alcohol or use of drugs including those protected under Title 242 of the Code of Federal Regulations, Part 2; Psychological or Psychiatric records, including communications made by me to a social workers, psychologist or psychiatrist; including behavioral or mental health services.

All records for any and all dates of evaluation, care or treatment to be disclosed.

Make disclosure to: York, Risk Services Group, Inc. PO Box 620 Howell, MI 48844‐0620

The purpose and need for disclosure is: At the request of the undersigned to process the above reference claim.

As a claimant, I may revoke this authorization by notifying the Custodian of Records of applicable health care provider in writing of my desire to revoke it. However, I understand that any action already taken in reliance on this authorization cannot be reversed, and my revocation will not affect those actions.

This authorization expires one year from the date of execution.

A PHOTOCOPY OR DIGITALLY SHARED COPY OF THIS DOCUMENT SHALL BE CONSIDERED VALID AS IF THE ORIGINAL WERE OFFERED.

Electronic SignatureBethany Pickens

Date02/22/2022