Supervisor Accident Report

Name(Required)

First Last

Name (Copy)(Required)

First Last

Employer Name(Required)

Employee & Injury Information

Employee Name(Required)

First Last

Employee Email

Employee Phone

Location/Department Code(Required)

Date of Hire(Required)

Date of Accident(Required)

Time of Accident(Required)

Body Part Injured(Required)

Nature of Injury(Required)

Medical Attention Required?(Required)

Approved Provider?

What was the employee doing when they were injured?(Required)

Where specifically did the accident occur?(Required)

Was First Aid Given?(Required)

BBP Exposure?(Required)

Your Premises?(Required)

Was the employee utilizing any required safety equipment?(Required)

Was this the employee’s normal job duty?(Required)

Recorded on OSHA Log?(Required)

Work Status(Required)

Actual Date Off Work?(Required)

Transitional Duty RTW Date

Full Duty RTW Date(Required)

Employee Wages(Required)

Did anyone witness the accident?(Required)

No. of Hrs Regularly Worked Per Week(Required)

WITNESS SHOULD COMPLETE FORM

Witness Name

First Last

Witness Phone

Did you remember to have any witnesses complete a Witness Statement Form?(Required)

ALL EMPLOYEES RECEIVING MEDICAL TREATMENT MUST PROVIDE YOU WITH THE TREATING PHYSICIANS RELEASE TO WORK PRIOR TO BEING ALLOWED TO RETURN TO WORK.

Any person who knowingly and with intent to defraud any insurance company or other person files a statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent act, which is a crime and may subject such person to criminal and civil penalties.

Supervisor’s Signature(Required)

Supervisor Accident Report

Employee & Injury Information

WITNESS SHOULD COMPLETE FORM

Work Injury

Group Health

Company