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
  • Name of Injured Employee: * Required
    If more than one employee injured, complete a separate incident form for each injured employee.
  • Date Format: MM slash DD slash YYYY
  • :
  • Date Format: MM slash DD slash YYYY
  • Be as specific as possible.
  • (What happened?) Be as detailed as possible.
  • (What caused it to happen?) Be as detailed as possible.
  • Person responsible for corrective action:
  • Drop files here or
    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.

  • This field is for validation purposes and should be left unchanged.