Supervisor's Report of Incident/Accident

Supervisor Name *

Supervisor Phone Number *

Supervisor Email *

Employee Name *

SSN:

Date of Birth +

Gender *

Position *

Hire Date +

Employee Street Address

Employee Phone Number

City

State *

Zip Code

Incident Department *

Incident Location * 🛈

Location Address *

Date of Incident * +

Day of Week *

Time *

Time of day *

a.m.

p.m.

Nature of Incident *

If Other where? *

Injured Body Part *

	Side		Area
Pick one of each.

Caused by *

If Other what? *

Explanation of Incident or Injury *

Please upload pictures of the incident area and any machinery or equipment involved.

Was blood or other bodily fluid present? *

If yes, was personal protective equipment used? *

	Name	Phone
Witness 1	Name	Phone
Witness 2	Name	Phone
Witness 3	Name	Phone

First Aid * 🛈

Observation/Rest

Ice/Elevation of injured part

Wound care

Other

Medical Care Needed * 🛈

If Other what? *

Injured Area * 🛈

Type of Injury *

Specify Side *

Specify *

Was this incident caused by an unsafe act or condition? *

Unsafe Act/Condition * 🛈

If yes, please explain: *

Could this injury have been prevented? *

Have similar incidents occurred before? *

If yes, please explain: *

Contributing Factors *

Action(s) to be taken to prevent recurrence *

Additional Comments * 🛈