The unsafe acts of people, and the unsafe conditions that cause accidents, can be corrected only when they are known specifically. This report will help to identify them and correct them. This report and investigation must be completed within 24 hours of the accident. The employee involved and his/her supervisor should cooperate to complete all the information requested. Please use additional paper as necessary.

PART I - General Information: Dept/Area: _______________________________________________________

Name of Injured: _____________________________________________ Employee #: _________________________

PART II – Employee’s Description of Accident (What Happened?)

Day / Date of Accident: ____________Time: ___ Exact Location:___________________________________

When was supervisor notified? ________________Who did you report the accident to? __________________

Job or Activity at Time of Accident: _________________________________________________________

Describe the Accident: ________________________________________________________________________

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Describe the Injury and body part(s) affected: _______________________________________________________

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Names of on duty supervisor and any witness(es):___________________________________________________

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Employee Signature: ____________________________Phone #:___________________Date:______________
(I certify that the information provided above is true and complete.)

PART III – Supervisor’s Investigation of the Accident: If you do not agree with the employee’s report, notify your Human Resources Manager and / or the Office of Workers Compensation immediately, and provide details with this report.

A. Describe any UNSAFE Acts: ___________________________________________________________________

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B. Describe any UNSAFE Conditions: _____________________________________________________________

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C. Identify the Cause(s) of the Accident: ___________________________________________________________

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PART IV - Corrective Action Taken
(What have you done or what do you recommend to prevent a recurrence of a similar accident?)

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Has corrective action been taken? ____________ If not, give Reason:_____________________________________

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PART V – Accident Analysis Details

Severity of Injury / Damage:

o Fatality o Lost Workdays o Medical Treatment (off premises) o First Aid (On site)
o Significant Property Damage

Panel of Physicians List Provided to Employee o Yes – Attach Copy to this report o No

Employment Category:

o Regular, Full-time o Regular, Part-time o Temporary o Contractor o Other: _____________

Time in Occupation at time of accident:

o Less than 6 months o 6 mos. to 2 years o 2 to 5 years o More than 5 years

Work Shift at time of accident:

o Day Shift o Evening Shift o Night Shift

Prepared by: (Name & Title)

Work Phone #:

Date Report Prepared:

Reviewed by: (Name & Title)

Work Phone #:

Date Report Reviewed:

Follow – up Action: __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

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