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SUPERVISOR'S REPORT OF ACCIDENT <br /> Employee's Name: Social Security No.: <br /> Job Title: Supervisor's Name: <br /> Date of Accident: Time of Accident: <br /> Location of Accident: <br /> Task being performed when accident occurred: <br /> Date and Time Accident was reported to you: <br /> Name of Witness (es): <br /> Accident resulted in: Injury Fatality Property Damage <br /> First Aid given: Medical Treatment required: <br /> Did employee lose work days: How many: <br /> Describe how the accident happened: <br /> What actions, events or conditions contributed most directly to this accident: <br /> What can be done to prevent this type of accident: <br /> Signature of Supervisor: Date: <br /> 15 <br />