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 Employee Information
Employees Legal Name*

First NameMiddle NameLast Name
Employee ID Number *
KCKPS employee number
Current Home Address*

Street Address

Street Address Line 2

CityState / Province

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

MonthDayYear
Date
Employee Home Phone Number*
Best Phone Number To Be Contacted; Area Code First
Employee Date of Hire*

MonthDayYear
Date
Employee Title / Occupation
Employee Duty Station*
Select Your Regular Duty Station
Information About the Injury
Location of Injury*
Select Location of Injury
Date & Time of Injury*

MonthDayYear
Date
Hour MinutesAM/PM Option
Describe How the Incident Occurred:*
What Was the Employee 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
Eyewitness Statement
Witness Name

First NameMiddle NameLast Name
Date of Incident

MonthDayYear
Date
Witness Phone Number
Please enter a valid phone number.
Witness Work Phone Number
Please enter a valid phone number.
Witness Occupation/Relationship to Injured Person
Witness Age
Witness Statement
In Your Own Words, Describe What You Saw.
Were There Any Other Witnesses

NoYes, Please Provide Their Names
Please Scan and Upload Any Eyewitness Statements
Supervisor Information
Supervisor's Name*

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

YesNo, Please Explain
Was the Employee Referred to a Medical Facility?*

YesNoIf Yes, What Facility?
Did the Employee Receive Medical Treatment?*

YesNoIf Yes, Describe The Treatment.
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
Principal / Director / Supervisor Signature*

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SUPERVISOR’S ACCIDENT INVESTIGATION REPORT

Injured Employee Information

Information About the Injury

Eyewitness Statement

Supervisor Information