Supervisor'S Report Of Employee Accident
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1ACTION by SO: YES _____ NO _____
The University of Tennessee
Date Rec'd: __________________
WORKERS' COMPENSATION
Supervisor's Report of Employee Accident
IN ORDER TO COMPLY with OSHA reporting regulations, Supervisors must provide the following information immediately
following all work-related injuries, whether medical treatment is required or not. Completed form should be routed to campus
Workers' Compensation office in accordance with campus procedures. This form must accompany the completed State of
Tennessee "Accident Report" claim form.
IMPORTANT: If the employee does seek medical attention, remind him or her that medical services must be from a State
network provider in order for medical expenses or lost time to be paid.
Name
Male
Female
(check one)
1. EMPLOYEE
Job Title
Personnel No.
Time employee began work ________________________
Cost Center
Date of Accident
Time of Accident
2. ACCIDENT
CIRCUMSTANCES
Date Reported
Time cannot be determined
Was employee engaged in job duties at the time of accident?
YES
NO
Describe the conditions or circumstances which caused this accident to occur (what, who, when, how and why). Please
be specific. Use additional paper if necessary.
Witnesses, if any
Extent of injury and affected body part/s
3. INJURIES
Was employee hospitalized for this injury overnight?
YES
NO
Was employee treated in an emergency room?
YES
NO
When did employee first receive medical treatment for this injury?
Where?
Will the employee lose work time other than the day of injury?
YES
NO
4. OUTCOMES
When?
How much?
Could this accident have been prevented?
Explain.
What actions will be taken to prevent future accidents?
5. OTHER
COMMENTS
Department
DEPARTMENT
INFORMATION
Name of Supervisor
Campus Phone
Supv. Signature
Date
rev. 3/2002
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