SUPERVISOR'S ACCIDENT/INJURY/INCIDENT INVESTIGATION REPORT
Dept./School: Address:
Employee Name: Date of Injury/Incident:
Date of Birth:
Employment Status:
Full-TimePart-Time Permanent Temporary Probationary
9 Month 10 Month 11 Month 12 Month
Length of Time in Position:
Was the employee performing regular job duties?
If not, explain:
Position Title: Work Shift Hrs:
Any recent changes to shift hours? (Explain)
Location of Accident: Day of Week:
Time of Day: Body Part Injured: Type of Injury:
Injury Severity:
First Aid Doctor Visit
Emergency Care Fatality
C-1 Completed:
C-3 Completed:
Date Completed:
Date Completed:
Lost Days from Work: Work Restrictions Issued:
Describe in
detail what
happened:
Did employee receive training in prevention of this type of injury: Training Date:
Describe any equipment damage/estimate cost:
WITNESSES: (Attach written statements. If non-CCSD employee, include work or home address)
Name: Job Title: Telephone:
Telephone:Name: Job Title:
Telephone:Name: Job Title:
Employee's Supervisor at time of injury:
9998-500099 CCF-99
02/20
Loc. #:
