EMPLOYEE INJURY REPORT FORM - SUPERVISOR FORM

Instructions for Supervisor

Complete this form within 48 hours of incident.
Contact the Department of Public Safety immediately.
If medical treatment is required, direct or facilitate transfer of employee to go to one of the facilities listed on the employee statement form.
Complete the “ACCIDENT/INCIDENT Investigative Form,” within 48 hours of incident.
Reminder: Under the N.C. Workers’ Compensation Act, the EMPLOYER chooses the physician/hospital for employee care. An employee’s failure to utilize an employer-directed physician could result in non-payable charges associated with the unauthorized provider and the employee will be responsible for subsequent expenses.

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Supervisor's Name

First Name*

Last Name*

Name of Injured Employee

First Name*

Last Name*If more than one employee injured, complete a separate incident form for each injured employee.

Public Safety Notified?*

Yes

Injured Employee

First Name

Last Name

Date and Time of Injury/Accident*

Date Injury Was Reported*

No. of Employees Injured

No. of Private Parties Injured

Location of Incident*Be as specific as possible.

Description of Accident

Cause of Accident

Corrective Action

Person responsible for corrective action

First Name

Last Name

I acknowledge that the above statement is a true and accurate representation of the information provided to me by the injured employee. By submitting this form electronically, you are giving consent to use this as acknowledgement of your electronic signature.

Public Safety

EMPLOYEE INJURY REPORT FORM - SUPERVISOR FORM

Instructions for Supervisor

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