Supervisor’s Accident Investigation

*To be completed by employee's supervisor or other responsible administrative official

First Name (Person Injured)

Last Name (Person Injured)

The Person Who Was Injured Is:

An Employee

Non Employee

Date & Time of Accident

Length Of Time Employee Has Worked In Their Specific Role Where Injury or Illness Occurred

Total Length of Time Employee Has Been With Aelieve One, LLC

Employee Job Title or Occupation

Department Employee Is Normally Assigned To

Did the Accident/Illness Occur on the Employer's Premises?

Yes (Iowa City Office)

Address of Accident/Illness

Who Is The Property Owned By?

Location/Area of Accident (kitchen, lobby, etc.)

What Property Was Damaged?

What Was The Employee Doing When Injury/Illness Occurred? What Machine/Tool? What Operation?

How Did Injury/Illness Occur? (list all objects and substances involved)

Describe Bodily Injury Sustained (be specific about body part(s) affected):

Supervisor Acknowledgement

Please Answer The Following Questions & Approve The Acknowledgement Statement Before Submitting The Form.

Supervisor's Corrective Action To Ensure This Type of Accident Does Not Reoccur:

Was Employee Retrained In The Appropriate Use Of Personal Protective Equipment/Proper Safety Procedures?

Yes

Was Employee Cautioned For Failure To Use Personal Protective Equipment/Proper Safety Procedures?

Yes

Supervisor First Name

Supervisor Last Name

Today's Date

I (the supervisor) affirm that the information and statements included in this form are true and accurate to the best of my knowledge, recollection, and understanding. I understand that my statements are confidential and may only be shared with management, human resources, and any state departments, agencies, or any other law enforcement agency having the authority to investigate the incident.