State of Wisconsin
University of Wisconsin System
SUPERVISOR’S ACCIDENT ANALYSIS AND PREVENTION REPORT
Within 24 hours of notice of the accident
complete this report.
Send report to the Worker’s Compensation Coordinator.
If you were not present at the time of injury, interview the employee.
Social Security Number Job Classification
Department Name and Location Work Unit
Date of Accident Time of Accident
Date injury reported
From your analysis, describe in detail the action, occurrence or event that resulted in the accident.
Identify the exact location where the accident took place: Repetitive activities, lifting or material handling, exposure to chemicals,
push/pull or slip and fall, etc. If equipment related, was it defective? Could it be modified to prevent further injuries? Were safety
procedures followed? Have employe’s job duties changed recently? If so please explain.
Safety devices or other equipment in use at time of accident:
What action could be taken to prevent a similar accident?
Do you agree with the employee's account of the accident?
No If NO, Please explain.
Has the employee ever reported any previous physical condition(s) associated with work or non-work activities (second job, sports,
etc. that could be related to or aggravated by this injury / illness?
No If YES, please explain
Supervisor's Name (Please Print) Date
Title Phone #
*If injury involved repetitive motion or material handling, Supervisor must complete reverse side*