SUPERVISOR’S ACCIDENT INVESTIGATION REPORT: WORKERS COMPENSATION

SUPERVISOR’S ACCIDENT INVESTIGATION REPORT

This form is to be filled out by the immediate supervisor for work related injuries only. Please complete within 24 hours of the injury. Even if medical care is not requested, the RPO (Report Only) option should be selected for documentation purposes. Once submitted, the form will automatically be sent to Risk Management. Please save a copy for your records following completion.
Employee Type *
When injured on assignment, please instruct Agency & Temp staff to notify their contracting agency immediately for medical care.
Report Type*
Injured Persons Contact Information
Legal Name*

First NameMiddle NameLast Name
Employee ID Number (If Applicable) *
KCKPS employee number
Current Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Social Security Number (Last 4 are required for processing)*
(Ex.000-00-1234)
Date of Birth*

MonthDayYear
Date
Best Phone Number To Be Reached *
Best Phone Number To Be Contacted; Area Code First
Date of Hire (Where Applicable)*

MonthDayYear
Date
Title / Occupation
Station of Duty*
Select the Location You Are Assigned to by HR
Information About the Injury
Location of Injury*
Select the specific location where the injury occurred
Date & Time of Injury*

MonthDayYear
Date
Hour MinutesAM/PM Option
In your own words, describe how the accident occurred:*
What Were You (the injured party) Doing When the Injury Occurred?
What Substance or Object Directly Caused the Injury?
Describe the Injury in Detail (Nature And Extent of Injury, Body Part Involved, etc.)*
Were You Working at Your Regular Job When the Injury Occurred?

YesNo, Please Explain
Did Anyone (Witness) Observe the Accident?

Yes (Please Complete Report By Eyewitness Form)No
If applicable, please provide the names of individuals who witnessed the accident directly (maximum 3)
Signature of Injured Party

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Eyewitness Information
Witness 1 Name & Contact Information

First NameMiddle NameLast Name
Date of Incident

MonthDayYear
Date
Best Phone Number to be Reached
Please enter a valid phone number.
Witness Age
Witness Occupation/Relationship to Injured Person
Witness 1 Statement (Type Here or Upload Written Statement Below)
In Your Own Words, Describe What You Saw.
Witness 1 Signature

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Were There Any Other Witnesses

NoYes, Please Provide Their Names
Scan and Upload Any Other Eyewitness Statements WITH signature included please.
Supervisor Information
Supervisor's Name*

First NameLast Name
Supervisor's Title*
Did Employee Request Medical Treatment?*

YesNo, Please Explain
Is there surveillance or pictures available of the accident or general area? If so, an opportunity to upload is available at the bottom of the screen. Hard copies are also accepted.

YesNo
Did the Employee Receive First Aid Treatment?*

YesNoIf Yes, Describe The Treatment.
Was the Employee Referred by Risk Management to a Medical Facility?*

YesNoIf Yes, What Facility?
Was the Accident Site Reviewed by Principal / Director / Supervisor?*

YesNo
Was the Employee Wearing / Using Required Safety Equipment?*

YesNo
What Safety Equipment Could Have Been Used to Prevent This Accident?*
How Could This Accident Have Been Prevented?*
What Immediate Action Was Taken to Prevent The Occurrence of a Similar Accident?*
Describe the Weather Conditions at the Time of the Accident (if Relevant)?*
Did the Accident Occur as Part of An Extra-Curricular Event or Special Activity?*

YesNoIf Yes, Identify the Activity
Principal / Director /Supervisor Additional Comments or Concerns
Principal / Director / Supervisor Signature*

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Annotate Image: 1. Select Color; 2. Select Line Width; 3. Select Pen; 4. Mark Up Diagram To Identify Body Parts Impacted. You can also use shapes and add text by selecting the T button. If you make a mistake, you can use the back button, or hit the Clear button at the bottom the image to reset.*
Do You Have Photographs or Video? If So, Please Upload Here.
Should be Empty:

SUPERVISOR’S ACCIDENT INVESTIGATION REPORT

Injured Persons Contact Information

Information About the Injury

Eyewitness Information

Supervisor Information