SUPERVISOR ACCIDENT REPORT FORM
Email address *
NAME OF SUPERVISOR *
Your answer
Phone number *
Your answer
EMPLOYEE NAME *
Your answer
OCCUPATION OF EMPLOYEE *
Your answer
TASK OR OCCUPATION OF EMPLOYEE WHEN INJURED? *
Your answer
Work Site *
What time did the employee arrive at work?
Time
:
DID EMPLOYEE HAVE A LOSS OF TIME FROM WORK *
Your answer
Date of Accident
MM
/
DD
/
YYYY
Time of Accident *
Time
:
Nature of Accident? *
Specific Side of Body of injury *
Part of body injured *
Required
Was injured person properly instructed in a safe and efficient method? *
Was necessary protective equipment worn? (if applicable) * *
Did injured report the injury to you, the supervisor, immediately? * *
Did injured person violate any instructions ? *
Did injured person violate any instructions ? *
Did poor housekeeping contribute to the accident ? *
Did horseplay cause the accident or injury ? *
Was it caused by something, which needed repairs ? *
Should a guard be provided ? *
Did any bodily defect contribute to the accident? *
Was it caused by an unsafe act *
Accident: Describe what injured was doing at time of accident, what happened, who was involved, nature of injury, part of body affected ? *
Your answer
Unsafe Act: What did the employee or another person do incorrectly, if anything ? *
Your answer
Remedy: What should be done to correct the condition, which caused the accident ? *
Your answer
Was the employee taken to Immediate Care ? *
Name of Dr. or hospital ? *
Your answer
List any unsafe condition which may have contributed to accident. *
Your answer
Please list any additional information about accident? *
Your answer
Who was in change when accident occurred. *
Your answer
WAS THE ACCIDENT IMMEDIATELY REPORTED TO YOU. *
DID THE EMPLOYEE RECEIVE ANY TYPE OF FIRST AID ? *
Please list witnesses to accident
Your answer
Please provide the specifics about the accident and how it occurred, contributing factors and potentially how it could have been prevented. *
Your answer
As a supervisor do you have any concerns of this accident being covered, if so please note
Your answer
A copy of your responses will be emailed to the address you provided.
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