Supervisor Accident Investigation Form

Emergency Preparedness

Supervisor Accident Investigation Form

Emergency Homepage

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: __________________

_________________________________________________________________________________

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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: _________________________________________________________________________

______________________________________________________________________________

_________________________________________________________________________________

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Steps taken to prevent similar incident: __________________________________________________

_________________________________________________________________________________

______________________________________________________________________________

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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

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