Supervisor'S Accident Investigation Form printable pdf download

Supervisor'S Accident Investigation Form

Dal-Tek Interiors Ltd.

Supervisor's Accident Investigation Form

Name of Injured Person ______ _________________ ___________________ _____ _

Date of Birth _______________ _

Address ___________________ _________________ ___________________ _______

City ______________________ _____________ State ___________ Zip __

u n ...

(Circle one)

Male Female

What part of the body was injured? Describe in detail. ____________________ _______________________

Telephone Number ___________________ _

What was the nature of the injury? Describe in detail. ____________________________________________

Describe fully how the accident happened? What was employee doing prior to the event? What

equipment, tools being using? ____________________________________________________________ _

Names of all witnesses:

Date of Event _____________________

Exact location of event:

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What caused the event?

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Time of Event

Were safety regulations in place and used? If not, what was wrong? _________________________________

Employee went to doctor/hospital? Doctor's Name ___________________________________________ _

Hospital Name ____________________________________________

Recommended preventive action to take in the future to prevent reoccurrence.

Supervisor Signature

Date

Supervisor'S Accident Investigation Form