Dot Supervisor'S Incident Investigation Report Of Occupational Injury Page 2
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DETAILS OF INCIDENT CAUSED BY CONTRIBUTING FACTORS
If incident was caused by unsafe job practice, is there a Written Operating Procedure for this activity?
□ Yes □ No
If Employee did not follow procedure, why not? ________________________________________________________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
Was Employee trained on this procedure? □ Yes □ No
Training Date ____/____/_____
Describe in detail the corrective action taken (training, progressive discipline, etc.) ____________________________________________
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
Have other accidents occurred with same process or procedure? □ Yes □ No
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
Does training need to be changed to better address this hazard? □ Yes □ No
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
Does work practice or written procedure need to be changed/updated to better address this hazard? □ Yes □ No
DETAILS OF INCIDENT CAUSED BY HAZARDOUS CONDITION
Is the responsibility for safety inspections in this area/vehicle assigned? □ Yes □ No If YES, to whom? ______________________
Have Site Safety Inspections been conducted according to a schedule? □ Yes □ No
Date of last Site Safety Inspection ____/____/_____
Did the hazardous condition exist at the time of the last inspection? □ Yes □ No
If defective equipment was involved, has it been taken out of service? □ Yes □ No
____/____/_____
Has the hazardous condition been previously identified? □ Yes □ No □ Verbally □ Written
If hazard was previously identified were actions taken to correct or mitigate the hazard? □ Yes □ No
If YES, nature of correction or mitigation steps taken ______________________________________________________________________
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
If NO, explain why no action was taken __________________________________________________________________________________
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
SUPERVISOR’S INFORMATION
What action(s) are you taking, as a Supervisor, to prevent future incidents of this type? ________________________________________
□ Correct Unsafe Condition
□ Retrain Employee(s)
□ Discipline Employee
□ Implement/Revise Operating Procedure
□ Revise Training Program
□ Modify/Upgrade Work Tools
□ Communicate Facts and Prevention Tips
□ C onduct More Frequent
with Employee and Other Employees
Safety Checks
□ Other (specify) ___________________________________________________________________________________________________
Supervisor’s Name/Title ________________________________________________________________________________________________
Department/Depot_________________________________________________________________ Work Phone ______________________
Supervisor’s Signature ______________________________________________________________________________ Date ____/____/_____
Distribution: 1. DOT Supervisor
2. DOT Depot Manager
3. Systemwide Safety Programs Team Leader, DFM, 45 W. Gude Drive, Suite 4000, Rockville
4. Risk Management Specialist, ERSC, 45 W. Gude Drive, Suite 1200, Rockville
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