Supervisor Accident/Incident Report Form

Incident/Accident Report

Completed by DPI Supervisor
This form is to be completed by the DPI Supervisor. The report that the employee needs to complete can be found here (or on the employee website safety page).

Each state has specific procedures due to the different insurance carriers:

Arizona - Traveler's

Delaware - Traveler's

Florida - TBD

Idaho - Traveler's Insurance

Maryland - Chesapeake (DS & FDSS), ALMA (DI)

Oregon - SAIF

Pennsylvania - State Workers Insurance Fund (SWIF)

Washington - Washington Labor & Industries (WA L&I)
Date

MonthDayYear
Division
State
This is a report of a:

Other
Employee Name

First NameLast Name
Employee Job Title
Report completed by

First NameLast Name
Email address (of person completing the form)
example@thedpigroup.com
Email address of your supervisor (or anyone else that should receive a copy of this report)
example@example.com
Date of incident/accident

MonthDayYear
Time of incident/accident

Hour Minutes

AM/PM Option
Location incident/accident occurred
License plate number of the DPI Vehicle:
Make/model of DPI Vehicle:
Description of incident/accident
Did the employee miss any days of work following the incident?
If 'yes' to above question, have they returned?
What part of the body was injured (if there was an injury)?
Did employee go to the doctor or hospital?
Were police involved?
During what part of employee's workday did incident occur?
Describe the location/environment at the time of the incident/injury:
Where did it occur, what was the weather like if that was a contributing factor, was it messy, hot, icy, noisy, etc.
How could this incident be avoided in the future? (Safety changes, coaching, etc.)
Witnesses
Upload any supporting documents

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Signature
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Incident/Accident Report