Supervisor's Report of Injury

Complete the form below and choose “Submit”.

Employee Name(Required)
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?
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)