Skip to main content Skip to main navigation Skip to footer content


Instructions for Supervisor
  • Complete this form within 48 hours of incident.
  • Contact the Department of Public Safety immediately.
  • If medical treatment is required, direct or facilitate transfer of employee to go to one of the facilities listed on the employee statement form.
  • Complete the “ACCIDENT/INCIDENT Investigative Form,” within 48 hours of incident.
  • Reminder: Under the N.C. Workers’ Compensation Act, the EMPLOYER chooses the physician/hospital for employee care. An employee’s failure to utilize an employer-directed physician could result in non-payable charges associated with the unauthorized provider and the employee will be responsible for subsequent expenses.


Supervisor's Name
Name of Injured Employee
If more than one employee injured, complete a separate incident form for each injured employee.
Public Safety Notified?*
Be as specific as possible.

I acknowledge that the above statement is a true and accurate representation of the information provided to me by the injured employee. By submitting this form electronically, you are giving consent to use this as acknowledgement of your electronic signature.