Get the free Supervisor Statement of Injury / Illness

Care Center Supervisor Statement of Injury / Illness To be completed by the Supervisor immediately upon notification of a work related injury / illness. Fax completed form within 24 hours of incident

How to fill out supervisor statement of injury

How to fill out supervisor statement of injury

1. Obtain the supervisor statement of injury form from the HR department or download it online.
2. Fill in the date of the injury, time and location where it occurred.
3. Provide details of the injured employee such as name, ID number, job title, and department.
4. Describe the nature of the injury, how it happened, and any potential contributing factors.
5. Include any witness statements or evidence related to the injury.
6. Sign and date the supervisor statement of injury form.

Who needs supervisor statement of injury?

1. Employees who have been injured on the job and are seeking workers' compensation benefits.
2. HR departments and insurance companies who need documented information about the injury.

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What is supervisor statement of injury?

The supervisor statement of injury is a formal document that provides details regarding an incident where an employee was injured at work. It includes information about the injury, the circumstances surrounding it, and any immediate actions taken.

Who is required to file supervisor statement of injury?

The supervisor of the employee involved in the injury is required to file the supervisor statement of injury. This is typically done by the direct supervisor or manager who witnessed the incident or is responsible for the workplace where it occurred.

How to fill out supervisor statement of injury?

To fill out a supervisor statement of injury, the supervisor should gather all necessary information, including details about the injured employee, a description of the incident, witnesses, and any medical attention provided. The form should be completed accurately and submitted to the appropriate office or department as per company policy.

What is the purpose of supervisor statement of injury?

The purpose of the supervisor statement of injury is to document the details of the incident for record-keeping, to assist in any investigations, and to support the injured employee's claim for workers' compensation if applicable.

What information must be reported on supervisor statement of injury?

Information that must be reported on the supervisor statement of injury includes the date and time of the incident, a detailed description of what happened, the names of those involved and any witnesses, the type of injury sustained, and actions taken immediately after the incident.