Supervisor’s Accident Investigation Form
Name of Injured Person
First Name
Last Name
DOB
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
-
Area Code
Phone Number
Gender
Male
Female
What part of the body was injured? Describe in detail.
What was the nature of the injury? Describe in detail.
Describe fully how the accident happened? What was employee doing prior to the event? What equipment, tools being using?
Names of all witnesses:
Date and Time of Event
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Exact location of event:
What caused the event?
Were safety regulations in place and used? If not, what was wrong?
Employee went to doctor/hospital? Doctor’s Name
First Name
Last Name
Hospital Name
Recommended preventive action to take in the future to prevent reoccurrence.
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Supervisor's Signature
p. 443.979.7171
AAA Physical Therapy, LLC
admin@AAAPhysicalTherapy.com
8975 Guilford Rd Ste 170
Columbia, MD 21046
f. 667.200.5908
Submit
Should be Empty: