Supervisor's Accident Investigation and Report form

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The Supervisor's Accident Investigation and Report form provides an essential element in establishing control of work-related accidents.  When properly utilized, it provides a tool for employers and supervisors to:

• Require immediate notification when injuries occur
• Complete First Report of Injury or Illness forms promptly
• Identify unsafe procedures or conditions
• Take corrective action to prevent similar accidents
• Retain a record for future reference

Fill out the form as soon as possible

It is important to complete the Supervisor's Accident Investigation and Report form as soon as possible and with a full description of the accident details.  The factors involved in each accident must be known to the employer so that corrective action can be taken.  This requires that the supervisor provide complete answers to the questions on the form.  Proper investigation will also enable supervisors to identify questionable claims and secure accurate information about the accident before pertinent details become faded or overlooked.

When to use the form

The form should be completed for all near-miss, property damage, or injury situations.  If an accident results in an injury requiring a physician's attention, the supervisor should submit the original form to whomever completes the First Report of Injury or Illness form.  The yellow copy of the Supervisors Accident Investigation and Report form should be kept in the booklet for record keeping and future reference.

The Supervisor's Accident Investigation and Report form does not replace the First Report of Injury or Illness form. A First Report of Injury must be submitted for any work-related injury or occupational disease requiring a physician's attention.

Your assigned risk management consultant has Supervisor's Accident Investigation and Report form booklets available and will assist you in implementing its use in your organization.
Sample Supervisor Accident Investigation and Report form [PDF]

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