Supervisor Injury Report
Campus:
  		 Department:
 
Employee Involved:
  		Employee Job Title:
 
  
   
1) When did the injury occur?
(Fill in both date and time)		 Date:
 		 Time:
 
2) Was it reported immediately?   
If no, what date was it reported?
  
3) Did the employee miss any time from work?
If Yes, please specify:		 Yes
Last Work Day:
 		No
Date Returned:
  
4) Describe exactly how the injury took place.  Describe what was actually being done at the time of the incident.  Include specific body part affected and any substances & equipment involved.
  
5) List any witnesses.   Forward witness statements to EHS via Email (ehs@cccd.edu) or District mail (Attn: District EHS Office).
  
6) What workplace conditions or work practices contributed to this incident?
  
7) Has the employee received safety training related to the above? Yes No
  
8) Were safe work practices neglected? Yes No
If Yes, please describe:
  
9) What corrective actions will be taken to prevent another occurrence?
  
10) Who is responsible for completing the corrective actions given above? Name:
 		Job Title:
  
11) Are there any personal factors you feel are relevant to the claim?  (For example: other employment, hobbies, sports/recreation, medical factors, etc.)
  
12) Provide any additional comments you wish to make regarding this injury.
  
Supervisor Name:
 		 Date:
 		 Phone: