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:______________________________________________