Supervisor’s Accident/Injury Investigation

Supervisor's Accident/Injury Investigation

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Location where accident occurred

Location of accident/injury

Date of accident/injury

Who was injured

Employee Non-Employee

Time of accident

Length of time with firm

Job title or occupation

How long has employee worked at job where accident or injury occurred?

What property/equipment was damaged?

Property/equipment owned by

What was the employee doing when injury/illness occurred?

What machine of tool was being used?

What type of operation?

How did accident/injury occur?

List all objects and substances involved.

Part of body affected/injured?

Any prior conditions? If do what?

Nature and extent of accident/injury and property damaged (be specific)

PLEASE INDICATE ALL OF THE FOLLOWING WHICH CONTRIBUTED TO THE ACCIDENT/INJURY

Improper instruction

Inoperative safety device

Lack of training or skill

Poor housekeeping

Operating without authority

Improper dress

Horseplay

Improper protective equipment

Physical or mental impairment

Unsafe equipment

Poor ventilation

Other

Supervisor's corrective action to ensure this type of accident does not recur

Was employee trained in the appropriate use of Personal Protective Equipment/Proper safety procedures?

Yes

Was employee cautioned for failure to use Personal Protective Equipment/Proper safety procedures?

Yes

Did employee promptly report the accident/injury?

Yes

Is there modified duty available?

Yes

Supervisor's Name

Supervisor's signature

Phone

Date

Supervisor's Accident/Injury Investigation

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