Supervisor's Accident/Incident Report

Reporting Guidelines:

  • Employee must report events to the attending supervisor immediately, and provide a signed statement for the A/I report.
  • Witnesses must also complete a signed statement for inclusion in the report.
  • Supervisor will conduct the preliminary investigation as outlined below, and report accordingly:
    • If an emergency, notify Security (x3500) immediately for response services.
    • If situation requires formal investigation and/or hazard elimination; OR if medical treatment beyond basic first aid is needed; OR if lost time is anticipated, notify the EHS Manager (x3314) and HR Services (x3837) immediately.
    • File the written accident/incident report with both EHS and HR within 24-hours regardless.

Important Filing Instructions: After complting this form, you will receive an email confirmation. You must print the email confirmation and all parties must sign that copy. The supervisor should retain the signed copy in their file.

Contact Information
Employee's Name:
 Email:
@bowdoin.edu		 Extension:
Supervisor's Name
 Email:
@bowdoin.edu		 Extension:
Department
Witness(es)
Other Employer(s)
Description of Accident/Incident
Incident Date (yyyy) Time: AM    PM
Shift Assignment Shift Time: AM    PM
Exact Location
Description
Response to Accident/Incident
First Aid Given? Yes    No First Aid Provider:
Medical Treatment Needed? Yes    No Medical Treatment Provider:
Lost Time Anticipated? Yes    No
If yes, Start Date: (yyyy) Start Time: AM    PM
Security or EHS/HR Notification? Yes    No
If yes, Call Date: (yyyy) Call Time: AM    PM
Specific response actions taken
Supervisor's Accident/Incident Investigation
Root Cause(s)?
(*physical hazard, repetitive stress, equipment failure, etc.)
Contributing Factors
(*weather, employee error, health conditions, etc.)
Policy/Procedure Violation(s)?
(*PPE use, following instructions, work habits, timely reporting, etc.)
Action(s) to prevent recurrence?
(*hazard elimination, equipment repair/replacement, employee counseling, etc.)

To submit this report click on the submit button :