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Supervisor's Accident Investigation Report

This accident investigation involves (check one or both): 

Personal Injury Property Damage


Department Date  

Time of occurrence a.m. p.m.


If Personal Injury

If Property Damage
Person Injured Equipment Involved
Nature of Injury Nature of Damage
Department Regularly Employed and Position Estimated Cost to Repair or Replace
Date of Hire    

Where did the accident occur?


What was employee doing when injured?


Describe the injury or illness.


How did the accident occur?


I am taking the following action to prevent recurrence: I recommend that the following steps be taken to prevent recurrence:


Date action will be taken    
Date Supervisor



To be completed by employee involved in accident
My supervisor and I have discussed the accident and my input is reflected in the analysis and corrective action. I feel that the following should be done to prevent recurrence of my accident to others:

Date Employee



All accidents that result in personal injury or property damage must be investigated and reported within 48 hours.