Accident/incident Report Form - University Of Alaska Fairbanks Page 2
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SECTION III: SUPERVISOR’S REPORT OF INCIDENT (completed by employee’s supervisor)
When were you notified of injury/illness? Date________________________________ Time ______:_______ ____AM ____PM
Do you agree with the employee’s incident information on side one? ____Yes ____No (provide comments below)
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What could have been done to prevent this accident?____________________________________________________________________________________
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What action have you taken to avoid any reoccurrence?__________________________________________________________________________________
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Supervisor’s name________________________________________________ Shop/Department________________________________________________
Supervisor Signature___________________________________________________________________ Date ______________________________________
Forward to EHS&RM via intercampus mail Box 8145, or fax at 474-5489
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SECTION IV: INVESTIGATION (completed by Safety Officer)
Background Information of Incident (provided by employee) validated ___Yes ___No (If no, provide comments_____________________________________
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Account of Accident (what happened-sequence of events, extent of damage, type of accident/hazard, agency or source of energy/hazardous material. etc.)
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Analysis of Accident (How/Why—Direct, indirect, and basic causes) _________________________________________________________________________
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Recommendations to Prevent a Recurrence ____________________________________________________________________________________________
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Safety Officer Name_______________________________________________________________
Safety Officer Signature________________________________________________________________________ Date_______________________________
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