Injury Investigation Form

Supervisor's Injury Investigation Form

Injured employee name*

Injured employee ID

Date & time of injury*

Date of this report*

Job Title of injured employee*

Assigned Campus/Location*

Location where injury occurred*

Was there lost time as a result of this injury?

Lost time began

Returned to work on

If applicable, have you reviewed their record of previous injuries with them?

Supervisor’s comments regarding cause of injury:*

What should be done to prevent recurrence of this type of injury in the future?*

What action will be taken to see that this is done?*

Supervisor Name*

Supervisor Email*

Please contact Jaime DeCantillon if there are questions - 281-897-4339