Employee Injury or Accident Report

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Part 1: Employee’s Report Part 2: Supervisor’s Report of Injury or Accident Investigation


PART 1: EMPLOYEE’S REPORT

TYPE THE INFORMATION INTO THE FORM, THEN PRINT AND GIVE TO SUPERVISOR

Employee: This form must be completed before end of shift in which incident occurred. Hand deliver completed form to supervisor or person in charge.

Supervisor: Immediately review and sign this form. Complete the Supervisor’s Investigation Report ASAP; SCAN AND EMAIL to Campus Safety and Human Resources.

Example: 919123456
(e.g., 1:35 p.m.)
(e.g., 8 a.m.)
CHECK AND COMPLETE ALL THAT APPLY BELOW:
Please type your full name.
Please have your supervisor type his/her full name.
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