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Supervisor Accident Investigation Form

 

NAME OF INJURED: ______________________________________________________________

JOB TITLE: ____________________________ SEX: _________ DATE OF BIRTH: __________

DATE OF INCIDENT: _________________ HOUR: _______________________ PHOTOS Y/N

DATE REPORTED: __________________ HOUR: ______________________

ACCIDENT LOCATION: _________________________________________________________

WITNESSES: NAMES; ADDRESSES; PHONE NUMBERS

1. ____________________________________________________________________

2. ____________________________________________________________________

TIME NOTIFIED: __________ TIME ON SCENE: ___________ TIME OFF SCENE: ________\

FIELD INVESTIGATION

EXACT LOCATION OF INCIDENT: _________________________________________________

_______________________________________________________________________________

Completely describe location of incident including lighting, walking surface, weather, measurements, and any other condition that could have contributed to or prevented the incident:

_________________________________________________________________________________

_________________________________________________________________________________

Describe injuries/illnesses which you observed or which were described to you: __________________

_________________________________________________________________________________

______________________________________________________________________________

Describe demeanor of person involved and include statements made as Excited Utterances:

_________________________________________________________________________________

_________________________________________________________________________________

Describe shoes, physical appearance or any other characteristic that would contribute to understanding how the accident occurred: ___________________________________________________________

_______________________________________________________________________________

______________________________________________________________________________

 

Describe how the incident occurred; state facts, contributing factors, cite witnesses and support evidence: _________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

______________________________________________________________________________

 

Steps taken to prevent similar incident: __________________________________________________

_________________________________________________________________________________

______________________________________________________________________________

_________________________________________________________________________________

 

Did employee seek medical care? (Check one) Yes _________ No _________

If yes, name of medical facility/doctor: ______________________ Date/Time: _________________

 

______________________     _________________________          _________________________

Investigators Signature        Date/Time form completed         Print Investigators Name

 

KEENAN & ASSOCIATES LIC. #0451271 ALL RIGHTS RESERVED

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