Supervisor Injury Investigation Report Form 

The Supervisor Injury Investigation Report should be completed by Supervisors immediately when a Caltech employee has a work-related injury or illness. The supervisor should conduct a thorough investigation and document as much information as possible, including witness statements if available. If you have reason to question the injury, please provide an explanation on a separate sheet of paper or call the Disability and Leave Administration Unit.

The completed Injury Investigation Report should be returned to the Disability and Leave Administration Unit at Mail Code 168-84 within three (3) working days from the date of knowledge of the injury/illness.

Note: The supervisor should always report the injury/illness to the Leave Administration Unit via telephone within 24 hours of knowledge of the injury/illness. The Injury Investigation Report should not replace the phoned in report.

If there are any questions, contact the Disability and  Leave Administration Unit at (626) 395-4577 or (626) 395-8382.

Do not submit a Supervisor Injury Investigation Report if no injury occurs.