Employee Injury Form (Supervisor’s Form)

Supervisor's Injury/Accident Investigation Form

Supervisors are required to complete and submit this form within 48 hours.

Alamance Community College Worker's Comp
Instructions for Supervisors:
- 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.
Supervisor's Name * Required
First Last
Name of Injured Employee: * Required
First Last
If more than one employee injured, complete a separate incident form for each injured employee.
Date of Incident: * Required
MM slash DD slash YYYY
Time of Incident: * Required

: Hours

Minutes

AM/PM AM/PM
Date Incident Reported: * Required
MM slash DD slash YYYY
No. of Employees Injured:
No. of Private Parties Injured:
Location of Incident * Required
Be as specific as possible.
Description of Incident: * Required
(What happened?) Be as detailed as possible.
Root Cause of Incident: * Required
(What caused it to happen?) Be as detailed as possible.
Corrective Action:
Person responsible for corrective action:
First Last
Additional File/Image
Drop files here or

Max. file size: 49 MB.
Upload any emails/correspondences, photos relative to incident.
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.
Email
This field is for validation purposes and should be left unchanged.

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Public Safety

Employee Injury Form (Supervisor’s Form)

Supervisor's Injury/Accident Investigation Form

Alamance Community College Worker's Comp

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.