Supervisor's Report of Injury

Complete the form below and choose “Submit”.

Employee Name(Required)
MM slash DD slash YYYY
MM slash DD slash YYYY
Time of Accident(Required)
:
Please include left/right
Supervisor Name(Required)

Witnesses

List all names with contact numbers
Witness 1
Witness 2
Witness 3
Was employee operating a vehicle?(Required)
Was injury fatal?
MM slash DD slash YYYY
Was First Aid given at the scene?(Required)
Was employee treated at ER?(Required)
Was employee hospitalized overnight as an inpatient?(Required)
Did employee return to work?(Required)
Signed By:(Required)
MM slash DD slash YYYY