Supervisor'S Accident/injury Investigation Report Template
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1Supervisor’s Accident/Injury Investigation Report
(To be completed by the employer’s supervisor or other responsible administrative official)
Employer’s Premises: Yes____ No ____
Location where accident/injury occurred:
Date of accident/injury:
Time of accident/injury: _______ a.m. / p.m.
Who was injured?
Employee______ Non-Employee_______
Job title or occupation:
Length of time with firm:
Name of dept. normally assigned to:
How long has employee worked at job where accident/injury
occurred?
What property/equipment was damaged?
Property/equipment owned by:
What was employee doing when accident/injury occurred?
How did accident/injury? List all objects and substances
What machine or tool was being used? What type of
involved?
operation?
Part of body affected/injured? Any prior physical
Nature and extent of accident/injury and property damaged
conditions? If so, what? Yes_____ No_____
(please be specific)
PLEASE INDICATE ALL OF THE FOLLOWING WHICH CONTRIBUTED TO THE INJURY OR ILLNESS:
____ Failure to lockout
____ Improper maintenance
____ Poor housekeeping
____ Failure to secure
____ Improper protective equipment
____ Poor ventilation
____ Horseplay
____ Inoperative safety devices
____ Unsafe arrangement or process
____ Improper dress
____ Lack of training
____ Unsafe equipment
____ Improper guarding
____ Operating without authority
____ Unsafe position
____ Improper instruction
____ Physical or mental impairment
____ 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___No____
Was employee cautioned for failure to use Personal Protective Equipment/Proper safety procedures?
Yes____No____
Did employee promptly report the accident/injury? Yes____ No____
Is there modified duty available?
Yes____No____
Supervisor’s Signature_____________________________Phone #________________Date___________
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Parent category: Business