Policy Handbook

Affinity:

Work Related Injury or Accident

Human Resources

JUNIATA COLLEGE

 

SUPERVISOR INVESTIGATION OF WORK-RELATED INJURY OR ACCIDENT

 

This form should be completed by all supervisors whenever an employee experiences an accident or injury.

 

Date of Injury:____________________        

Location of Injury/Accident: ____________________________________

 

Employee’s Name:______________________________________Department:____________________________

 

Describe the accident:

 

______________________________________________________________________________

 

______________________________________________________________________________

 

______________________________________________________________________________

 

 

What was the cause of the accident (Unsafe Act vs. Unsafe Condition)? ____________________________________________________________________________________________________________________________________________________________

What steps will be taken to prevent similar accidents? __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Did you personally witness this accident or injury? ____________________________________________ 

Witnesses: ____________________________________________________________________________

______________________________________________________________________________

 

Witnesses’ Account: ________________________________________________________________________________________________________________________________________________________________________________________________________________­__________________________

 

Signature of Supervisor: __________________________________Date: ________________

 Additional comments: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Please complete this form within 24 hours after an accident or injury and return to Human Resources with First Report of Injury/Notice of Rights & Duties forms.

Shaded area to be completed by Safety Committee.

 

Action taken:___________________________________________________

 

_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

 

Signature:______________________________________________________Date:__________________

 

Notified Supervisor:_____________________________­­­_________________

 

 


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