Employee's Report of Injury Form - Free Download | Page 2
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Employee's Report of Injury Form Page 2
2
Supervisor’s Accident Investigation Form
Name of Injured Person _________________________________________________
Date of Birth _________________ Telephone Number ____________________
Address ______________________________________________________________
City _____________________________ State_______ Zip _____________
(Circle one) Male Female
What part of the body was injured Describe in detail. ________________________________________
_____________________________________________________________________________________
What was the nature of the injury Describe in detail. _________________________________________
______________________________________________________________________________
______________________________________________________________________________
Describe fully how the accident happened What was employee doing prior to the event What
equipment, tools being using ____________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Names of all witnesses:
______________________________________ _______________________________________
______________________________________ _______________________________________
Date of Event ______________________ Time of Event _________________________________
Exact location of event: _________________________________________________________________
What caused the event _________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Were safety regulations in place and used If not, what was wrong ______________________________
_____________________________________________________________________________________
Employee went to doctor/hospital Doctor’s Name ___________________________________________
Hospital Name __________________________________________
Recommended preventive action to take in the future to prevent reoccurrence.
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
______________________ ___________
Supervisor Signature Date
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Employee's Report of Injury Form