Spo Supervisor'S Incident Investigation Report Of Occupational Injury
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1
2Division of School Plant Operations (SPO)
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 ____/____/_____
School/Facility ______________________________________________________________________ Work Phone____________________
Job Title ____________________________________________________ Date of Hire ____/____/_____ Gender □ Male □ Female
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 Building Service Supervisor? □ 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, 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 (broom, mower, vacuum, etc.)
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
Describe the specific activity employee was performing when event or exposure occurred (waxing floor, descending stairs, etc.)
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
Was this injury/illness/incident caused by contributing factors (job practices, acts, etc.)?
□ Yes □ No If YES, explain:
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
Was this injury/illness/incident caused by an unsafe condition?
□ Yes □ No If YES, explain:
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
SPO • December 2013 • 0549.14 • EGPS
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