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:
*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.