docFirst Report of Injury/Supervisor Accident Report
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First Report of Injury/Supervisor Accident Report
SUPERVISOR’S ACCIDENT INVESTIGATION REPORT Injured Employee:_____________________________________SS#_______________________ Home Phone #_________________________Cell #___________________DOB:_____________ Marital Status: Married Widowed Separated Single Divorced Job Title: _____________________________Accident Location:_________________________ Date of Injury: __________________________Time of Injury:___________________________ Date Reported: ___________________________Last Day Worked:_______________________ Did this Accident Require Doctor or Hospital Services? Yes No If yes: Name and Address of Doctor/Hospital:_______________________________________ ______________________________________________________________________________ Time Work began for the day:_____________________________________________________ Did Employee Return to Work? Yes No If Yes, date returned:__________________ Describe injury or alleged injury : __________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ Part of Body Injured:__________________________________________________________________ Type of Injury, i.e.: cut, sprain:____________________________________________________________ Witnesses: ___________________________________________________________________________ Did Equipment malfunction? : Yes No If yes, describe:_____________________________ _____________________________________________________________________________________ What caused the accident? :_____________________________________________________________ REVIEW BY SUPERVISOR Recommendations:_____________________________________________________________________ _____________________________________________________________________________________ Supervisor’s Signature _____________________________________Date:________________________ Pampa ISD does not discriminate on the basis of race, color, national origin, sex, disability, or age. El Distrito de la Escuela Independiente de Pampa (PISD) no discrimina en base a raza, color, origen nacional, sexo, discapacidad, o edad
