SUPERVISOR’S INCIDENT INVESTIGATION

REPORT FORM

INSTRUCTIONS

This form is to be completed by the supervisor of an employee that has experienced an incident resulting in a serious injury or illness. It shall be completed in a timely manner following an incident and can also be used to investigate a near-miss event that could have resulted in an accident or injury. Return completed form to:

THIS FORM SERVES TO DOCUMENT select all that apply
DEATH	LOST TIME	ER / CLINIC TREATMENT	FIRST AID ONLY	NEAR MISS

REPORT COMPLETED BY Name and Title	DATE OF INCIDENT	DATE OF REPORT

INJURED EMPLOYEE INFORMATION

EMPLOYEE NAME	EMPLOYEE ID	DATE OF BIRTH
JOB TITLE AT TIME OF INCIDENT	DEPARTMENT
EMPLOYEE TYPE full or part-time, contract, etc.	Length of time doing this job:	NAME OF OTHER EMPLOYER if applicable
NATURE OF INJURY select all that apply
Abrasion, scrapes	Amputation	Broken Bone	Bruise	Burn (heat)
Burn (chemical)	Concussion	Crushing Injury	Cut, laceration, puncture
Hernia	Illness	Sprain, strain	Damage to body system
Other, describe:
DESCRIPTION OF INJURY	PART OF BODY AFFECTED shade all that apply

INCIDENT DETAILS

LOCATION	DATE OF INCIDENT	TIME
During what part of the employee’s workday did the incident occur?
Entering or leaving work	Doing normal work activities
During meal period	During break	Working overtime
Other, describe:
WITNESSES if any
PROTECTIVE EQUIPMENT List any personal protective equipment used at the time of the incident.
INCIDENT DESCRIPTION Describe tasks being performed and sequence of events. Attach additional pages as necessary.
ATTACHMENTS List anything to be submitted with this report (forms, witness statements, photographs, maps, drawings, etc.)

WHY DID THE INCIDENT OCCUR?

UNSAFE WORKPLACE CONDITIONS select all that apply	UNSAFE ACTS BY PEOPLE select all that apply
Inadequate guard	Operating without permissions
Unguarded hazard	Operating at unsafe speed
Safety device is defective	Servicing equipment that has power to it
Tool or equipment is defective	Making a safety device inoperative
Workstation layout is hazardous	Using defective equipment
Unsafe lighting	Using equipment in an unapproved way
Unsafe ventilation	Unsafe lifting
Lack of necessary personal protective equipment	Taking an unsafe position or posture
Lack of appropriate equipment / tools	Distraction, teasing, horseplay
Unsafe clothing	Failure to wear personal protective equipment
No training or insufficient training	Failure to use the available equipment / tools
Other; Describe below:	Other; Describe below:
Why did the unsafe conditions exist?
Why did the unsafe acts occur?

Is there a workplace culture, norm, or expectation 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

HOW CAN FUTURE INCIDENTS BE PREVENTED?

What changes do you suggest to prevent this incident / near miss from happening again? select all that apply
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; Describe below:
What should be (or has been) done to carry out the suggestion(s) selected above?

REPORT DETAILS

REPORT WRITTEN BY
NAME	TITLE
DEPARTMENT	DATE

REPORT REVIEWED BY
NAME	TITLE
DEPARTMENT	DATE

INVESTIGATION TEAM MEMBERS
NAME	TITLE

REPORT SUBMITTED BY

NAME	SIGNATURE	DATE

REPORT RECEIVED BY

NAME	SIGNATURE	DATE

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