THE UNIVERSITY OF TENNESSEE
SUPERVISOR'S REPORT OF EMPLOYEE ACCIDENT
| IMPORTANT: Supervisors must complete this form immediately following all employee work related accidents. Route this form and/or copies in accordance with the campus procedures* for reporting employee accidents. This form does not take place of the regular State of Tennessee Accident Report Form (claim form). |
| 1. Employee | 2. SS# |
| 3. Job Title | 4. Date of Accident |
| 5. Location of Accident | 6. Date Reported |
| 7. Extent of Injury and affected body part(s)
|
| 8. Witness(es), if any
|
| 9. State what conditions or circumstances caused this accident to
occur. Tell the What, Who, When, Where, How and Why. Be specific (use additional paper if
necessary).
|
| 10. Was the employee engaged in his/her job duties at time of
accident? YES NO If no, explain
|
| 11. Could this accident have been prevented? YES
NO If yes, explain
|
| 12. What action(s) will you take to prevent future accidents?
|
| 13. Will the employee lose any time from work other than the day of injury? YES NO UNKNOWN |
| 14. Other comments
|
| Print name of Supervisor | Campus Phone |
| Signature of Supervisor | Date |
| Campus | Department | ACCT# |
Created 4/22/98 |
Modified 3/01/02 |