"Supervisor's First Report of Injury Form - Bentley University"

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Supervisor’s First Report of Injury Form
Employee’s Name:
Department:
Job Title:
Date of Injury:
Time:
Location Where Injury Occurred:
Name of Witness:
Injured Body Part(s):
Nature of Injury (burn, fracture, cut, etc.):
Describe how injury occurred:
Is medical attention required?
Is employee able to continue working?
Was the employee wearing/using Personal Protection Equipment?
Supervisor’s Name:
____________________
Supervisor’s Signature: ____________________ Date : __________________
Please submit this form to Human Resources.
Supervisor’s First Report of Injury Form
Employee’s Name:
Department:
Job Title:
Date of Injury:
Time:
Location Where Injury Occurred:
Name of Witness:
Injured Body Part(s):
Nature of Injury (burn, fracture, cut, etc.):
Describe how injury occurred:
Is medical attention required?
Is employee able to continue working?
Was the employee wearing/using Personal Protection Equipment?
Supervisor’s Name:
____________________
Supervisor’s Signature: ____________________ Date : __________________
Please submit this form to Human Resources.
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