Supervisor’s Accident Investigation

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