Supervisor's Report of Incident/Accident
Completed by DPI Supervisor
This form is to be completed by the injured employee's supervisor.
The report that the employee needs to complete can be found
here
(or on the
employee website safety page
).
If you need a Workers' Compensation training refresher, go through this
quick course
.
Each state has specific procedures due to the different insurance carriers and you can find them
here
.
Date
-
Month
-
Day
Year
Date Picker Icon
Division
*
Please Select
CSN
DPI Staff
FDSS Services
Meadowlark
Northwest Success
Security
Staffing
State
*
Please Select
Arizona
Delaware
Florida
Idaho
Maryland
New Mexico
Oregon
Pennsylvania
Virginia
Washington
This is a report of a:
*
Accident
Minor Injury (cuts and scrapes)
Assault
Disease/Exposure
Chemical/Inhalation
Car Accident
Verbal Assault/Conflict
Property Theft/Distruction
Death
Other
Employee Name
*
First Name
Last Name
Employee Job Title
*
Report completed by
*
First Name
Last 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
*
-
Month
-
Day
Year
Date Picker Icon
Time of incident/accident
*
Hour Minutes
AM
PM
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?
*
Yes
No
If 'yes' to above question, have they returned?
Have they returned?
*
Yes
No
Other
What part of the body was injured (if there was an injury)?
*
Please Select
Select best answer(s)
Right Ankle
Left Ankle
Right Arm
Left Arm
Right Foot
Left Foot
Right Wrist
Left Wrist
Right Hand
Left Hand
Head
Groin
Right Knee
Left Knee
Neck
Right Shoulder
Left Shoulder
Back
Brain
Buttocks
Chest
Did employee go to the doctor or hospital?
*
Please Select
Yes
No
I don't know
Were police involved?
Please Select
Yes
No
I don't know
Were police involved?
*
Yes
No
Did the police make a report?
*
Yes, I have a copy
Yes, but I just have the number
No
I don't have the number or a copy yet
Police report number:
*
Once you obtain copy of the police report, please send to
safety@thedpigroup.com
Upload a copy of the police report:
*
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Choose a file
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of
During what part of employee's workday did incident occur?
*
Please Select
Entering/leaving work
During normal work activities
During meal period
During break
Working overtime
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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Drag and drop files here
Choose a file
Cancel
of
Signature
*
Submit
Should be Empty: