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FACTS OF ACCIDENT
(Supervisor's Report of Accident)

Employee Information
  Employee Name:
  Job being performed at the time of accident:
  Immediate Supervisor's name (please Print):
  Location of accident:
  Date and time of accident:
  Witnesses of accident:

Precise Detail of accident:

What could have been done to prevent the accident?

Was the accident investigated?
Yes
No
If yes, by whom?
Has the employee had a similar injury?
Yes
No
If yes, give a date.
Was employee taken to an emergency room?
Yes
No
Has the employee returned to work full duty?
Yes
No
Have you received a doctor's note returning the employee to full-duty?
Yes
No

What corrective measures, if any, have been made?

Supervisor, it is very important that if your employee was seen by a doctor that you have a doctor's note releasing him/her to full of light duty. Please note that no employee who has been seen by a doctor for a work-related injury may return to work without a work slip. It is important that this work slip is turned into the Human Resources office. If you have any questions regarding this information, please contact the Human Resources office at x3675. Mahalo
Risk Management Links
Workers' Compensation
TDI
Points of Interest
Sexual Harassment

Risk Management Forms
Vehicle Accident Investigation Form
Witness Statement Form
Employee Accident Report
Facts of Accident
TDI
BYUH Property-Loss Claim Form
NONBYUH Property-Loss Claim Form
BYUH Building & Structures Loss-Claim Form
BYUH Report for Nonwork-Related Injuries
Request For Certificate of Insurance