SUPERVISOR’S ACCIDENT INVESTIGATION REPORT: WORKERS COMPENSATION

SUPERVISOR’S ACCIDENT INVESTIGATION REPORT

This form should only be completed by the immediate supervisor or location administrator of USD 500 employees, who have been injured in the course of completing regular job functions. Forms are to be submitted immediately, or within within 24 hours of the injury, even if medical care is not requested. The RPO (Report Only) option is for documentation purposes only. The Workers Compensation Claim option should be selected if medical care is needed. All workers compensation claims require preauthorization from Risk Assessment PRIOR to receiving medical treatment. When completing this form, please save a copy for your records and call (816) 907 0611 for preauthorization.
Employee Type
If injured while on assignment, please instruct Agency & Temp staff to notify their agency hiring manager immediately for medical care.
Report Type
Injured Persons Contact Information
Legal Name

First NameMiddle NameLast Name
Social Security Number (Last 4 are required for processing)
(Ex.000-00-1234. Please confirm with employee for accuracy)
Employee ID Number (If Applicable)
KCKPS employee number. Please confirm for accuracy
Current Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Best Phone Number To Be Reached
Best Phone Number To Be Contacted; Area Code FirstFormat: (000) 000-0000.
Date of Hire (Where Applicable)

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
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
2 digit month, 2 digit day, 4 digit yearDate
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 Object or Substance 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?

No, Please Explain
Did Anyone (Witness) Observe the Accident?
If applicable, please provide the names of individuals who witnessed the accident directly (maximum 3)
Signature of Injured Party
Eyewitness Information
Witness 1 Name & Contact Information

First NameMiddle NameLast Name
Date of Incident

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Best Phone Number to be Reached
Please enter a valid phone number.Format: (000) 000-0000.
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
Were There Any Other Witnesses

Yes, 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?

No, 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.
Did the Employee Receive First Aid Treatment?

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

If Yes, What Facility?
Was the Accident Site Reviewed by Principal / Director / Supervisor?
Was the Employee Wearing / Using Required Safety Equipment?
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?

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