Supervisor'S Review Of Work-Related Injury Report Form
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1SUPERVISOR’S REVIEW OF WORK-RELATED INJURY REPORT
WITHIN 24 HOURS OF NOTICE OR KNOWLEDGE OF ANY INJURY, SUBMIT THE
FOLLOWING TO YOUR HUMAN RESOURCE DEPT.
1. Employee’s Report of Injury - completed and signed
2. Signed Certificate Authorizing Release of Medical Information (Workers’ Comp. Board Form #220)
3. This Supervisor’s Review - completed and signed
1. Name of Injured Employee:__________________________________________________________________________
2. Date of Injury:________________________ 3. Type of Injury:_____________________________________________
4. Date and Time you received notice, or had knowledge of the injury: _____/______/______
_____:______ am/pm
5. Who informed you?________________________________________________________________________________
6. Person(s)not listed on the Employee’s Report who might provide further information about the
incident:___________________________________________________________________________________________
6a. Name and position:________________________________________________________________________
6b. Work address and phone:___________________________________________________________________
7. In your review of this Employee’s Report of Injury, did you find it complete, consistent and accurate?
Yes
No
7b. If no, what item or items were missing, incomplete, inconsistent or innacurate?_________________________
____________________________________________________________________________________________
8. Was this injury (check only one)
Avoidable
Unavoidable
8b. If avoidable, what could have been done?_______________________________________________________
____________________________________________________________________________________________
9. What corrective measures have or are being taken?________________________________________________________
10.Had this employee been trained in preventing this type of injury?
Yes
No
11. In order to determine contributing factors, please select any of the activities that you know the injured employee participates
in, performs or enjoys when not on the job (select all that apply) before and/or after the injury:
Outdoor sports or activities
Hunting / Fishing
Home Renovations / Projects
Crafting
Snowmobiling / Off-roading
Motorcycling
Knitting / Crocheting
Other Hobbies
Other motor sports
Woodworking
Cycling / Other Sports
Other
12. Please describe activities checked off above:
__
Your Name and Title:_______________________________________________________________________
Your Normal Work Hours:____________________________
Work Phone:_____________________________
Signature:_________________________________________________________
Date:______/______/______
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Parent category: Business