Supervisor's Accident Investigation Report
Suwannee County
Date:
Employee Name:
Address:
City:
State:
ZIP:
Social Security #:
DOB:
Phone #:
Job Title:
Hire Date:
Wage Rate:
Department:
Supervisor's Name:
Accident Location:
Accident Date:
Accident Time:
Date Injury Reported:
Witness (1) Name:
Phone #:
Witness (2) Name:
Phone #:
Who was Notified?:
Name of Doctor or Hospital:
Employee returned to work?:
Yes
No
If no, anticipated return date:
Description of Injury:
Description of Accident:
Did equipment malfunction?:
Yes
No
If yes, describe malfunction:
Describe damage to equipment or property:
As you reviewed the facts, what caused this accident?:
What action has been or will be taken to prevent recurrence?:
Additional Comments:
Employee Signature:
Date:
Supervisor Signature:
Date:
Your Name:
Your E-Mail*:
*must be valid e-mail address!