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Supervisor’s Detailed Assessment of Employee Accident*

___________________________________________ ____________________________

Injured Employee’s Name Date of Accident

1. Type of Accident:

2. Cause -- be as specific as possible and provide as much detail as possible:

3. Hazard Assessment of Accident/Work Area: (Please have campus police take photographs ASAP and submit the photographs to HR to supplement your accident report.)

4. Refresher Training:

5. Lessons Learned:


____________________________________

Supervisor’s Signature/Date

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Department/Campus

*Please attach to Employers Accident Report form. This is important to ensure that all relevant information regarding the accident can be better understood and if a safety hazard exists or something can be reasonably be done to prevent recurrence, those items can be addressed.