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- Accident Investigation FORMS (Bowie State University)

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Accident Investigation FORMS
Accident investigation forms/statements should be filled out by the
injured employee, supervisor and any witness to the accident.
Train your supervisors to conduct the preliminary investigation as soon as possible.
IMPORTANT - Care must be taken to assure the investigation is fact finding, not
fault finding. Obtaining signed statements as soon as possible following an accident
ensures that you, the employer, have an accurate account of how the injury occurred.
These completed statements are important in helping to correct hazards and prevent
the accident from recurring. They also help to spot possible third-party liability as
well as possible fraudulent claims.
After I have these forms completed, what do I do with them?
Please send the completed forms to your Claims Adjuster and keep a copy for your
files. These completed forms can provide valuable information in a claims investi-
gation of an injury and for developing the defense in the event of a workers’ comp
hearing.
What if my injured employee is physically unable to fill out the
Employee’s Report of Injury?
Use common sense and good judgement. If the injury is severe, remember, your em-
ployee’s health and care are first and foremost. If possible, have the form filled out at
a later, more appropriate time when the employee is physically able to document the
accident.
What if my employee refuses to fill out or sign an Employee’s Report of
Injury?
Of course, you cannot make an employee fill out the document. You can, however,
stress the importance of getting his or her account of the accident to set the record
straight and to help prevent the accident from happening again. Also, still obtain the
supervisor's report as well as any witness statements.
What if my Employee has retained an attorney? Can I still ask the
injured employee to fill out an Employee’s Report of Injury?
Yes. You, the employer, as part of your company’s accident management plan, can
still ask the employee to fill out the report form.
How to use
these
importantI
Chesapeake Employers' Insurance Company • 8722 Loch Raven Boulevard, Towson, MD 21286-2235 • www.ceiwc.com
Need Help?
If you would like
assistance in setting up
supervisory training
on how to use these
forms, please contact
your Chesapeake Claims
Adjuster or Safety
Management Consultant
at 1-800-264-4943.
Forms may be copied
as needed.
Forms are also
available for printing
in pdf format online at
www.ceiwc.com.
Employee's Report
of Injury Form
Accident Witness
Statement Form
Supervisor's Accident
Investigation Form
-
TOOLS
Includes:
i
Rev. 3/14
Employee's name: ____________________________________________________ Male____ Female____
Date of birth: ____/____/____ Home telephone # ( ______ ) _________________________________
Marital status: M / D / W / S Height/Weight: ______" /______ lbs. ____Right- or ____left-hand dominant
Home address: ___________________________________________________________________________
City: ______________________________________________ State: ______ Zip Code: _________________
Current job position: __________________________________ How long employed here: _____________
Social Security No.: _______-______-__________ Weekly salary: ________________________________
Location of accident:______________________________________________________________________
Date of accident: _________________________________________ Time of accident: __________________
Describe fully how accident occurred (including events that occurred immediately before the accident):
_______________________________________________________________________________________
_______________________________________________________________________________________
Describe bodily injury sustained (be specific about body part(s) affected): ___________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
Recommendation on how to prevent this accident from recurring:____________________________________
_______________________________________________________________________________________
Name of supervisor: _________________________________________ Phone #_______________________
Name(s) of witness(es): ______________________________________ Phone #_______________________
When did you report the accident to your supervisor? ____________________________________________
To whom did you report the injury?_____________________________________________________________
Do you require medical attention? Yes:_______ No:_______ Maybe:__________
Name of your treating physician:________________________________ Phone #______________________
Signature of employee: ________________________________________ Date: ______________________
Last First Middle
Address and location of accident (loading dock, bathroom, etc.)
Last First
Attach witness(es) report(s)
Chesapeake Employers' Insurance Company • 8722 Loch Raven Boulevard, Towson, MD 21286-2235 • www.ceiwc.com
Form may be copied as needed.
(To be completed by the employee only.)
Employee's
Report of Injury
Policyholder:
Policy #:
Rev. 3/14
Note: form must be signed by hand
Married
Injured employee's name: ___________________________________________________________________
Name of witness: ___________________________________________________ Phone # __________________
Job title of witness: _________________________________________ How long employed here?_________
Home address of witness: ___________________________________________________________________
City: ______________________________________________ State: ______ Zip Code: _________________
Is witness any relation to the injured employee? ___Yes ___No If yes, what relation? _________________
Location of accident: ______________________________________________________________________
Date of accident: _________________________________________ Time of accident: __________________
Describe fully how accident occurred (including events that occurred immediately before the accident):
_______________________________________________________________________________________
_______________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Describe bodily injury sustained (be specific about body part(s) affected): ____________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
Recommendation on how to prevent this accident from recurring:____________________________________
_______________________________________________________________________________________
Name of witness' supervisor: _________________________________________ Ph #_________________
Signature of witness: ________________________________________ Date: ________________________
Last First Middle
Address/name of building; area (bathroom, etc.)
Last First
Last First Middle
Chesapeake Employers' Insurance Company • 8722 Loch Raven Boulevard, Towson, MD 21286-2235 • www.ceiwc.com
Form may be copied as needed.
(To be completed by accident witness.)
Accident
Witness
Statement
Policyholder:
Policy #:
Rev. 3/14
Note: form must be signed by hand
(To be completed by the employee's supervisor or other responsible administrative official.)
Location where accident occurred: Employer's Premises: Yes No Date of accident or illness:
Job site: Yes No
Who was injured? Employee Non-employee Time of accident a.m.
If non-employee, specify______________________ p.m.
Length of time with firm: Job title or occupation: Name of dept. normally assigned to: How long has employee worked at job
where injury or illness occurred?
What property/equipment was damaged? Property/equipment owned by:
What was employee doing when injury/illness occurred? What machine or tool was being used? What type of operation?
Part of body affected/injured? Any prior physical conditions? If so, what?
Yes No
Nature and extent of injury/illness and property damaged (be specific):
PLEASE INDICATE ALL OF THE FOLLOWING WHICH CONTRIBUTED TO THE INJURY OR ILLNESS
____ Failure to lockout ____ Improper maintenance ____ Poor housekeeping
____ Failure to secure ____ Improper protective equipment ____ Poor ventilation
____ Horseplay ____ Inoperative safety device ____ Unsafe arrangement or process
____ Improper dress ____ Lack of training or skill ____ Unsafe equipment
____ Improper guarding ____ Operating without authority ____ Unsafe position
____ Improper instruction ____ Physical or mental impairment ____ Other ______________________
Supervisor's corrective action to ensure this type of accident does not recur: ________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
______________________________________________________________________________________________________
Was employee trained in the appropriate use of Personal Protective Equipment/proper safety procedures? ...Yes ___ No ____
Was employee using the appropriate Personal Protective Equipment/proper safety procedures at the time? .... Yes ___ No ____
Did employee promptly report the injury/illness? ..............................................................................................Yes ___ No ____
Is there modified duty available? ........................................................................................................................Yes ___ No ____
Supervisor's name Supervisor's signature Phone # Date
Chesapeake Employers' Insurance Company • 8722 Loch Raven Boulevard, Towson, MD 21286-2235 • www.ceiwc.com
Rev. 3/14
Form may be copied as needed.
Supervisor's Accident
Investigation Form
Policyholder:
Policy #:
How did injury/illness occur? List all objects and substances involved.
Was the accident the result of another party's negligence? If so, name of the negligent party:
Do you have any concerns about this alleged accident or injury? If so, please specify:
Note: form must be signed by hand
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Completed 18 August 2020

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