Supervisor’s Accident Investigation

Name of Injured Person*

Date of Birth*

Phone*

Address*

City*

State*

Zip*

Male or 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*

: HH

MM

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.

Signature*

Date*