Supervisor Accident Report
Name of injured
*
First Name
Last Name
Date and time of accident
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Job title
*
Department
*
Type of accident
*
Part of body injured - Please be detailed
*
Unsafe condition?
*
Yes
No
Describe the conditions
*
Describe any mechanical, physical, or environmental condition that may have caused this accident.
Possibility of subrogation
*
Yes
No
Unsafe Act?
*
Yes
No
Describe the act
*
What personal protective equipment was being used if any?
*
Describe in detail what happened
*
Please list any witnesses.
*
Attach any necessary statements or documentation
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Supervisor Name
*
First Name
Last Name
Signature
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