Supervisor Accident Investigation Report

The tools you need.

Supervisor accident investigation report.

Documenting when your employees get injured or sick on the job.

Supervisor Accident Investigation Report.

To be completed by the employee’s direct supervisor.
  • Supervisor Report (to be completed by the employee's direct supervisor)

  • Date Format: MM slash DD slash YYYY
  • Accident Investigation

    Accident Sequence: Instructions: Describe in reverse order of occurrence, events preceding the injury and accident. Starting with the injury and moving back in time, reconstruct the sequence of events that led to the injury.
  • Injury Classification

  • Witness Interviews

  • Causal Factors

    (Check all factors that contributed to the accident)
  • Corrective Actions

    (Corrective actions must be listed for all accidents)
  • Date Format: MM slash DD slash YYYY
  • I hereby declare that the statements provided in this document are; to the best of my knowledge and belief, complete and true. Fraud Notice: Any individual filing misleading or incomplete information knowingly and with the intent to defraud is in violation of the law and may also be subject to criminal and civil penalties. Note: By typing my name below I am electronically signing this form.
  • Date Format: MM slash DD slash YYYY
  • This field is for validation purposes and should be left unchanged.