Accident Investigation Forms

Accident investigation forms should be filled out by the:

  • Injured employee;

  • Supervisor; and

  • Any witness(es) to the Accident. (Tip: Make sure witnesses and injured employee fill out the forms in separate private areas.)

Train your supervisors to conduct the preliminary accident investigation and to have these forms completed as soon as possible:

Accident Investigation Forms - PDF - English

Accident Investigation Forms - PDF - Spanish

IMPORTANT - Care must be taken to assure the investigation is fact finding, not fault finding. Obtaining signed statements as soon as possible following an accident ensures that you, the employer, have an accurate account of how the injury occurred. These completed statements are important in helping to correct hazards and prevent the accident from recurring. They also help to spot possible third-party liability as well as possible fraudulent claims.

After I have these forms completed – what do I do with them?

Please send the completed forms to your Chesapeake Employers' claims adjuster and keep a copy for your files. These completed forms can provide valuable information in a claims investigation.

What if my injured employee is physically unable to fill out the Employee's Report of Injury?

If the injury is severe, remember your employee's health and care is first and foremost. Use good judgment and, if possible, have the form filled out at a later, more appropriate time when the injured employee is physically able to document the incident.

What if my employee refuses to fill out or sign an Employee's Report of Injury?

Of course, you cannot make an employee fill out the document. You can, however, stress the importance of getting "his" or "her" account of the accident to help prevent the injury from happening again. Still obtain the supervisor's report as well as any witness statements.

What if my employee has retained an attorney? Can I still ask the injured employee to fill out the Employee's Report of Injury?

Yes – you, the employer, as part of your company's accident management plan, can still ask the employee to fill out the report form.

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