Supervisor’s Accident Investigation Supervisor’s Accident Investigation Form Name of Injured Person* Date of Birth* MM slash DD slash YYYY Phone*Address* City* State* Zip* Male or Female* 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* MM slash DD slash YYYY Time of Event* : Hours Minutes AM PM 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?* Yes No Doctor’s Name Hospital Name Recommended preventive action to take in the future to prevent reoccurrence.Signature*Date* MM slash DD slash YYYY
