Accident or Incident Investigation Report
This report is to be completed by the supervisor with the assistance of the affected employee. Answer All Questions
Employee Name Date of Accident
Department Work Phone #
Nature of Injury/Exposure
Description of Event: What was employee doing just before and at the time of the incident? What happened or what work conditions contributed
(e.g. repetitive motion during pipetting in laboratory, slipped on water on floor in front of ice machine)?
Hazard Communication
Not recognized/identified Breakdown in verbal communication Personal protective equipment (See below)
Identified but not addressed Breakdown in written communication Faulty equipment
Inadequate repair Confusion after communication Poor/inadequate maintenance
Other ____________________ Inappropriate use
Work Procedures Missing guards
None developed Obsolete/antiquated equipment
Not followed Other Inadequate design
Partially followed Ergonomic factors
Not understood Equipment failure
Not appropriate Trip hazard
Not communicated Slip hazard
Other ___________ Struck by
Other ______________________
Training & Certification
Insufficient training PPE Requirements
Circumstances not covered Req. Used Type
Ineffective training Eye
Worker not authorized
Extended work hours
Worker fatigue
Physical overexertion
Work in elevated area
Chemical Use
Biological agent
Outdated Training Hearing
Prevention – Describe all corrective actions taken to prevent recurrence (e.g. initiated work order for sidewalk repair, retrained
workers on use of eye protection, installed ergonomic keyboard/mouse tray).
Person responsible: _____________________________________________________________Expected Completion Date _______________
Person responsible: ______________________________________________________________Expected Completion Date ______________
Supervisor Name ___________________________________________ Title_________________________________ Phone ________________
Signature ___________________________________________________ Date ________________________ Email _______________________
Employee Name _____________________________________________ Title_________________________________ Phone _______________
Signature (if available) ________________________ Date ________________________ Email _______________________________
Witness Name:______________________________Signature ______________________________________________
Supervisor/Director Name:______________________________Signature ______________________________________________
Please send completed forms as well as any questions or comments to Facilities and Safety Services at .
Factors that contributed to accident/incident – Please check all that apply.
NOTE: If an accident/incident resulted in an injury, please refer to the "How to report an accident or injury" form located on page 2.
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How to report an Accident or Injury
Call AmeriSys at 800-455-2079 to report the workers’ compensation claim. They will ask for the information
: Record the employee’s seven digit employee ID number at the top of the page.
NAME: Print the employee’s first name and last name, as it is on file with Florida Polytechnic University
HOME ADDRESS: Print the employee’s home address that is on file with FPU, and please include city, state and
zip code.
TELEPHONE: Print the employee’s telephone number that is on file with FPU, including area code.
OCCUPATION: List the employee’s occupation as recorded by FPU.
DATE OF BIRTH: List the employee’s date of birth.
SEX: Select the corresponding box, male or female.
SOCIAL SECURITY NUMBER: Print employee’s social security number that is on file with FPU.
DATE OF ACCIDENT: Indicate the date the accident occurred.
TIME OF ACCIDENT: Indicate what time the accident occurred, and remember to check either “AM” or “PM.”
EMPLOYEE’S DESCRIPTION OF ACCIDENT: Being as descriptive as possible, indicate how the accident occurred.
Be sure to explain what the cause of the accident was. Include the name of the employee's direct supervisor or
contact person’s name and campus phone number.
INJURY/ILLNESS THAT OCCURRED: In a brief term, print a description of the injury. (Ex. Bruise, strain, cut, scrape,
contusion, etc.)
PART OF BODY AFFECTED: Indicate the body part(s) affected by the injury. Be sure to specify “left” or “right”
when appropriate, and be specific as to the area injured (Ex. “left wrist,” “right knee”, “lower right back”).
DATE FIRST REPORTED: Write the date on which the injury was first reported to employee's supervisor. If you are
using the current form on the website, the next sections (**) will be completed for you.
Employer’s Location address: Florida Polytechnic University
Address: 4700 Research Way
Lakeland FL, 33805-8531
Telephone: 863-583-9050
Main Campus Location #: 0272
Florida Industrial and Phosphate Research Institute location #: 0273
If you need additional assistance, contact Human Resources at 863-874-8421 or email DeAnn Doll at Please report the accident to Facilities and Safety Services at 863-874-8426.