Division of Maintenance (DOM)
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
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EMPLOYEE INFORMATION
Name _________________________________________________________ ID Number____________ Date of Birth ____/____/_____
Work Phone ________________________________________________ Date of Hire ____/____/_____ Gender □ Male □ Female
Job Title ___________________________________________________________________________________________________________
Depot □ Bethesda □ Clarksburg □ Randolph □ Shady Grove
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 Division of Maintenance Assistant Director? □ 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 if available □ 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, etc.) __________________________________________________________________________
On MCPS premises? □ Yes □ No School/Facility Where Event Occurred ______________________________________________
Were others injured? □ Yes □ No
Equipment, tools, materials, or chemicals the Employee was using when the event or exposure occurred (using power tools,
backhoe, mower, other, etc.) _________________________________________________________________________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
Describe the specific activity employee was performing when event or exposure occurred ___________________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
Was this injury/illness/incident caused by contributing factors (job practices, acts, etc.)?
□ Yes □ No If YES, explain:
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
Was the injury/illness/incident caused by an unsafe condition?
□ Yes □ No If YES, explain: ______________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
DOM • October 2013 • 0549.14 • EGPS