Supervisor Accident Report

Supervisor's Investigation of Accident Report

This form must be completed for all employee injuries. Please be as thorough as possible. This information will be used to prevent future injuries of this type.

Name of injured employee(Required)

First Last

Date of Injury(Required)

MM slash DD slash YYYY

Time of injury(Required)

Hours

Minutes

AM/PM

Employee job title when injured?(Required)

Was injured employee doing his regular job?(Required)

What safety instructions had been given to the employee regarding the hazards of his job?

Describe injury or illness in detail, including part of body affected, type of injury and treatment received.(Required)

How did the accident take place, include events leading up to the accident. Please be as detailed as possible.(Required)

What environmental factors (unsafe conditions) contributed to the accident?

What behavioral factors (unsafe conditions) contributed to the accident?

If machine error, has the condition been corrected? If "No", when will the condition be corrected?

What safety equipment was provided to employee at the time of the accident? Was it being properly used at the time of the injury?(Required)

Were there any witnesses to this injury? If so, please identify. (plus to add more)

When were you first notified of this injury?(Required)

What action has been taken to prevent a similar accident/injury?

What are your recommendations for additional action?

Medical Information

Was employee taken to the hospital?

Which hospital

Please forward any paperwork received from the doctor to the Office.

Supervisors Printed Name(Required)

First Last

Supervisors Signature(Required)

Date(Required)

MM slash DD slash YYYY

Supervisor's Investigation of Accident Report

Medical Information

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