Supervisor's Report of Work-Related Injury
University of Maryland Baltimore County
To be completed by the supervisor or higher authority and submitted with all other reports to Workers' Compensation
Employee Information
Injured Employee First Name
Injured Employee Last Name
Injured Employee Email
Date of Accident
Time of Accident
hh:mm AM/PM format
Employer/Supervisor Notified Date
Location
Bldg. and Area (hall way, office, etc)
Accident Details
describe the work-process you were engaged in, give the purpose of the function or task, describe how the injury occured, and explain the cause
Part of Body Injured
be specific - example: right middle finger, left ankle, upper back
Type of Injury
example; sprain, sutured, contusion, burn {degree of burn}
Describe any factors that may have contributed to the injury or illness
No of days worked with restrictions
0
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Witness Information
Name
Job Title
Phone
Name
Job Title
Phone
Name
Job Title
Phone
Information
Do you agree with the employee's description of the accident?
Yes
No
If no, explain
.
Was safety equipment provided?
Yes
No
Was safety equipment used?
Yes
No
If no, explain
.
Recommendation on how to prevent this accident from recurring
Name of Supervisor
Department of Supervisor
Work Phone No
Email
By clicking the submit button below I affirm the information provided above is accurate to the best of my knowledge