Ncsu Supervisor'S First Report Of Injury Form Page 4

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SUPERVISOR’S CLAIM INVESTIGATION
31) When did the Supervisor (or another Supervisor or other management employee) first become aware that the
Employee was asserting that he/she was injured as a result of their employment? [Who was notified, date, and time]
If the injury was not reported within 24-hours, please describe the Employee’s reason for the late notice.
32) Please describe the investigation performed by the Supervisor (or other management employee) upon receipt of
notice of the Employee’s alleged injury. Do you have any reason to question the Employee’s account of the injury? If
so, why?
33) Do you believe further investigation is necessary? If so, please describe the investigation that you believe should be
performed.
34) What part(s) of the body did the Employee claim was/were injured?
Are you aware of the Employee having
complaints of other injuries or treatment to that part of the body prior to his/her incident? If so, please describe.
35) Were there any witnesses to the injury? If so, please identify the witnesses and have them provide their account in a
written statement. What is the relationship between the witness and the Employee? Was the witness also injured in
this event?
I have read this report and I have accurately reported the information obtained from the investigation performed at this
time. Should I receive additional information I will notify EH&S and Leave Administration.
Supervisor’s Signature: _______________________________________
Date: __________________________
Page 4 of 4
Rev. 09/2015

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