Test – Supervisor Injury/Illness Investigation Report

Instructions: Complete this form after an incident that results in serious injury or illness.
Must be turned in to Human Resources, no later than 48 hours after the incident.

This Is a Report of a: *

• Lost Time
• Dr. Visit Only
• First Aid Only
• Near Miss

Date of Incident: *

This Report Is Made By: *

• Employee
• Supervisor
• Team
• Other

Other:

Step 1: Injured Employee (Complete This Part for Each Injured Employee)

Name: *

First

Last

Age: *

Department:

Job Title at Time of Incident:

This Employee Works:

• Regular Full Time
• Regular Part Time
• Seasonal
• Temporary

Months With This Employer:

Months Doing This Job:

Part(s) of Body Affected (List All That Apply): *

Nature of Injury (Most Serious One): *

• Abrasion, Scrapes
• Amputation
• Broken Bone
• Bruise
• Burn (Heat)
• Burn (Chemical)
• Concussion (To the Head)
• Crushing Injury
• Cut, Laceration, Puncture
• Hernia
• Illness
• Sprain, Strain
• Damage to a Body System
• Other

Step 2: Describe the Incident

Exact Location of the Incident: *

What Part of Employee’s Workday?

• Entering or Leaving Work
• Doing Normal Work Activities
• During Meal Period
• During Break
• Working Overtime
• Other

Names of Witnesses (If Any):

Attachment(s):

Drag & Drop Files, Choose Files to Upload You can upload up to 3 files.

Attachments can include written witness statements, photographs, maps/drawings, etc.

What Personal Protective Equipment Was Being Used (If Any)?

Describe, Step-By-Step the Events That Led up to the Injury. Include Names of Any Machines, Parts, Objects, Tools, Materials And Other Important Details. *

for incidents yes,

Step 3: Why Did the Incident Happen?

Unsafe Workplace Conditions (Check All That Apply):

• Inadequate Guard
• Unguarded Hazard
• Safety Device Is Defective
• Tool or Equipment Defective
• Workstation Layout Is Hazardous
• Unsafe Lighting
• Unsafe Ventilation
• Lack of Needed Personal Protective Equipment
• Lack of Appropriate Equipment / Tools
• Unsafe Clothing
• No training or insufficient training
• Other

Other:

Why did the unsafe conditions exist?

Unsafe acts by people: (Check all that apply)

• Operating without permission
• Operating at unsafe speed
• Servicing equipment that has power to it
• Making a safety device inoperative
• Using defective equipment
• Using equipment in an unapproved way
• Unsafe lifting
• Taking an unsafe position or posture
• Distraction, teasing, horseplay
• Failure to wear personal protective equipment
• Failure to use the available equipment / tools
• Other

Other:

Why did the unsafe acts occur?

Is there a reward (such as “the job can be done more quickly”, or “the product is less likely to be damaged”) that may have encouraged the unsafe conditions or acts? *

• Yes
• No

If yes, describe:

Were the unsafe acts or conditions reported prior to the incident? *

• Yes
• No

Have there been similar incidents or near misses prior to this one? *

• Yes
• No

Step 4: How can future incidents be prevented?

Checkboxes

• Stop this activity
• Guard the hazard
• Train the employee(s)
• Train the supervisor(s)
• Redesign task steps
• Redesign work station
• Write a new policy/rule
• Enforce existing policy
• Routinely inspect for the hazard
• Personal Protective Equipment
• Other

Other:

What should be (or has been) done to carry out the suggestion(s) checked above?

Additional Description:

• Description continued on attached sheets

Supervisor responsible for Corrective Activity: *

First

Last

Date Completed: *

Submit