PART 1: REPORT OF ACCIDENT

Employee’s Name:_______________________________________Department:____________________

Date of accident:______________________________ Time of accident:_______________ ™ A.M. ™ P.M.

• Where did the injury occur? (please be specific)_____________________________________________

____________________________________________________________________________________

• What specific part of the body was injured?_________________________________________________

____________________________________________________________________________________

• What was type of injury? (i.e. cut, slip, burn)________________________________________________

• Please describe the accident in detail:_____________________________________________________

____________________________________________________________________________________

• Was this a re-occurrence of a previous injury? ™ Yes ™ No

• Who witnessed the accident?____________________________________________________________

Please attach witness statements from each individual.

• What type of medical treatment was provided? (please circle applicable item)

1. None 2. First Aid (on location) 3. Clinic or Doctor’s Office 4. Hospital or ER

Note: In the case of items 3 or 4 (above), an Oregon Workers’ Compensation form 801 is required. This must be completed and forwarded to Human Resources within 48 hours of injury.

• Did the employee: (please circle applicable item)

1. Immediately return to work

2. Go home and not work on the day of injury only

3. Go home and has not returned to work yet

4. Other (please specify)_______________________________________

Employee Signature: _____________________________________ Date: _____________________

PART 2: SUPERVISOR’S INVESTIGATION OF ACCIDENT (Mandatory)

• Was the employee performing job duties within the course and scope of employment when the accident occurred? Yes No

• Have you verified the facts of the incident with the employee and witnesses? Yes No

(Please list any discrepancies in the comments section below)

• Was the accident reported by the injured worker to a supervisor immediately? Yes No

If no, why not?_________________________________________________________________________

• Was the employee using safety equipment when the accident occurred? Yes No N/A

If no, why not?_________________________________________________________________________

• Do you have any reason to question the validity of this claim? Yes No

If yes, please explain why?_______________________________________________________________

• What was the specific cause of this accident?_______________________________________________

____________________________________________________________________________________

• What steps have been taken to prevent any other similar accidents?_____________________________

____________________________________________________________________________________

• Additional Information or Comments_______________________________________________________

____________________________________________________________________________________

Investigating Supervisor:______________________________________ Date:_____________________

Department Head:___________________________________________ Date:_____________________

Please return this form to:

Klamath County Human Resources - Risk Management

305 Main Street, Government Center 216, Klamath Falls, Oregon 97601-6332

Phone (541) 883-4296 or (888) 339-KCHR • Fax (541) 883-4270