NAME OF EMPLOYEE

EMPLOYER

DEPT.

DATE OF ACCIDENT

TIME

DID EMPLOYEE LOSE TIME FROM WORK?

YES

NO

HOURS LOST ON DATE OF ACCIDENT

HAS EMPLOYEE RETURNED TO WORK?

YES

NO

JOB TITLE

YEARS OF SERVICE WITH EMPLOYER Number of years

YEARS IN PRESENT JOB

PLEASE ANSWER THE FOLLOWING: CHECK "YES" OR "NO"

1. WAS INJURED PERSON PROPERLY INSTRUCTED IN SAFE AND EFFICIENT METHODS?

YES

NO

2. DID INJURED PERSON VIOLATE ANY INSTRUCTIONS?

NO

YES

3. WAS NECESSARY PROTECTIVE EQUIPMENT WORN? (IF APPLICABLE)

YES

NO

4. DID POOR HOUSEKEEPING CONTRIBUTE TO INJURY?

NO

YES

5. DID HORSEPLAY CAUSE THE INJURY?

NO

YES

6. WAS IT CAUSED BY SOMETHING WHICH NEEDED REPAIRS?

NO

YES

7. SHOULD A GUARD BE PROVIDED?

NO

YES

8. DID ANY BODILY DEFECT CONTRIBUTE TO INJURY?

NO

YES

9. WAS IT CAUSED BY AN UNSAFE ACT?

NO

YES

10. DID INJURED REPORT THE INJURY TO YOU, THE SUPERVISOR, IMMEDIATELY?

YES

NO

ACCIDENT. (DESCRIBE WHAT INJURED WAS DOING AT TIME OF ACCIDENT, WHAT HAPPENED, WHO WAS INVOLVED, NATURE OF INJURY, PART OF BODY AFFECTED.)

WITNESSES' NAMES

UNSAFE ACTS. (WHAT DID THE EMPLOYEE OR ANOTHER PERSON DO INCORRECTLY?)

UNSAFE CONDITIONS. (WHAT UNGUARDED OR UNSAFE CONDITION OF MACHINERY, EQUIPMENT, BUILDING OR PREMISES WAS INVOLVED?)

ACTIONS TAKEN. (WHAT DID YOU DO TO CORRECT THE CONDITIONS WHICH CAUSED THIS INJURY?)

REMEDIES. (WHAT SHOULD YOUR ORGANIZATION DO TO PREVENT OTHER INJURIES LIKE THIS?)

MEDICAL CARE. DID EMPLOYEE GO TO DOCTOR OR HOSPITAL?

YES

NO

IF YES, COMPLETE THE FOLLOWING: NAME OF DOCTOR OR HOSPITAL

DATE OF INITIAL VISIT

ADDRESS

TELEPHONE NUMBER

AS SUPERVISOR, DO YOU FEEL THAT THIS INJURY SHOULD BE COVERED UNDER THE TWC PROGRAM?

YES

NO

REASONS WHY

REPORT SUBMITTED BY

DATE

Supervisor's Report of Accident