Dot Supervisor'S Incident Investigation Report Of Occupational Injury

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Department of Transportation (DOT)
Supervisor’s Incident Investigation Report of Occupational Injury
Supervisors are responsible for calling CorVel Corporation at 1-888-606-2562
to file Employer's First Notice of Loss (FNOL) within 24 hours of incident.
FOR A FATALITY OR HOSPITALIZATION, CALL 301-370-2141 IMMEDIATELY
Page 1 of 2
EMPLOYEE INFORMATION
Name _________________________________________________________ ID Number____________ Date of Birth ____/____/_____
Work Phone ________________________________________________ Date of Hire ____/____/_____ Gender □  Male □  Female
Job Title ___________________________________________________________________________________________________________
Depot □  Bethesda □  Clarksburg □  Randolph □  Shady Grove N □  Shady Grove S □  West Farm
Scheduled Hours Per Week □  40 Hours or ____ number of hours Time Work Began ___:___ □  a.m. □  p.m.
Reported to Immediate Supervisor? □  Yes □  No Reported to Bus Operations Manager? □  Yes □  No
DETAILS OF INJURY, ILLNESS, EXPOSURE OR INCIDENT
____/____/_____ Time of injury ___:___ □  a.m. □  p.m. □  Daylight □  Dark
Date of injury
Specific injury and body part affected _________________________________________________________________________________
Medical diagnosis determined □  Yes □  No
Was Employee seen by a medical professional? □  Yes □  No
Did Employee receive medical evaluation and/or treatment? □  Yes □  No
Date of Supervisor’s first knowledge/notice of injury ____/____/_____
Was Employee hospitalized overnight?
□  Yes □  No Date of Death (if applicable) ____/____/_____
Reported to Systemwide Safety Programs?
□  Yes □  No Fax: 301-279-3061
Reported to Risk Management Specialist, ERSC?
□  Yes □  No Fax: 301-279-3642
INVESTIGATION OF INJURY, ILLNESS, EXPOSURE OR INCIDENT
Incident location (specify location, room, bus lot, bus number, etc.) _______________________________________________________
On MCPS premises? □  Yes □  No
School/Facility where Event Occurred (Route #/Road) ___________________________________________________________________
Were others injured? □  Yes □  No
Equipment, tools, materials, or chemicals the Employee was using when the event or exposure occurred (broom, wheel chair lift,
changing tire, etc.) __________________________________________________________________________________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
Describe the specific activity employee was performing when event or exposure occurred (driving/making turn, descending stairs, etc.
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
Was this injury/illness/incident caused by contributing factors (job practices, acts, etc.)?
□  Yes □  No If YES, explain:
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
DOT • October 2013 • 0549.14 • EGPS

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