Download Supervisor`s Accident Investigation Report

Accident Investigation Report
Please complete thoroughly and email to Desirée Mertz, HR.
Note to Supervisor
Remember that an
accident investigation is
not designed to find fault
or blame. Rather, it is a
tool to find causes that
can be controlled or
eliminated.
Completing the
Investigation
Try to answer these
questions:
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Who was injured?
What materials,
equipment,
machines or other
conditions were
involved?
Why did the
accident happen?
When did the
accident happen?
Where did it
happen?
How did the
accident occur?
Date:
HR # (HR will complete):
Employee/ Property Involved:
Position:
Date Employed:
Supervisor:
Department:
How long has employee been in this job?
Was the employee trained?
Yes
No
Severity of Injury (HR will complete)
OSHA Recordable?
Yes
First- aid only
Medical treatment only
Fatality
Lost workday (away from work)
Date lost time began:
Date restricted time began:
RTW date:
Type of Injury
Fall from elevation
Fall on same level
Struck against
Struck by
Puncture
Caught in, under, or between
Rubbed or abraded
Bodily reaction
Overexertion
Contact w/ electrical current
Contact w/ Temp. Extreme
Contact w/ other
Public transportation accident
Motor vehicle accident
Slip
No
Near Miss
Restricted duty
Unknown
Other
(describe below)
Nature of Injury
Abrasion
Amputation
Burn
Contusion
Crushed
Foreign Body
Fracture
Inhalation
Laceration
Puncture
Rash
Strain
Sprain
Skin Contact
Rep. Motion
Illness/Infection
Other
(describe below)
Face
Finger
Foot/feet
Groin
Hand
Head
Internal Organs
Leg
Multiple
Neck
Torso
Trunk
Wrist
Other
(describe below)
Body Part Injured
Arm
Back
Eye
Details of injury (example: laceration of third finger on left hand):
Date of accident:
Date reported to supervisor:
How did accident occur?
Time of accident:
Time employee began work:
Cause of accident:
Is there a policy pertinent to this accident? If so, what is it and was it followed? (i.e. lockout tagout, PPE, etc.)
Witnesses Name:
Dept./Address:
Phone Number:
Make
Recommendations
No accident investigation
is complete unless
corrective action is
suggested and
implemented.
Recommendations to prevent a recurrence:
What action has been taken or planned to date?
Follow-up
Determine and
document what action
has been taken on your
recommendations.
Supervisor’s Signature (initials if emailing):
Employee’s Signature (initials if emailing):
Safety Committee Comments
Endorses actions indicated above
Recommendations:
Additional Comments:
Diagram or Photo:
Date:
Date:
Make new or additional recommendations