Supervisor'S Accident Investigation Report Form
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1Supervisor’s
Accident
Investigation
Report 207-1
The Supervisor must complete this form with the employee and
then forward it to the Human Resources office, along with the 207
report, within 24 hours after the incident.
General InformatIon
Employee Name
Date of Incident
Location of Incident
Time of Incident
Medical Treatment?
Job Title
ER
First Aid
None
Walk-In
Ambulance
Other
Nature of Injury
IncIdent descrIptIon:
type of IncIdent: (check most appropriate, define other if checked)
Assault by public
Slip/Trip/Fall
Cut/laceration/puncture
Caught in/on/between
Lifting/Material Handling
Exposure (air quality, etc.)
Shoved by or against an object
Foreign body in eye
Other
Contact with heat/cold/chemical
Cumulative trauma
Motor Vehicle Accident
Repetitive motion
causes/contrIbutInG factors
apply
Check all that
condItIons
behavIors
Hazardous process
Poor lighting
Failure to follow safety procedure
Unsafe body mechanics
Weather conditions
Poor design
Failure to use PPE
Employee attitude on safety
Equipment not available
Carpet/mat
Improper technique
Horseplay
Poor housekeeping
Chemicals/cleaning agents
Using equipment unsafely
Failure to use lookout/tagout
Equipment malfunction
Improper PPE
Inappropriate dress or footwear
Inattention/disfunction
Ergonomic set-up
Lack of training
Failure to obtain assistance
Poor judgement responding
Floor/ground condition
to unsafe condition
Working at unsafe speed
Other
Performing task without knowledge/failure to ask
Failure to recognize unsafe condition
Not in scope of duties
actIon plan to prevent recurrence
Additional training
Hepatitus B vaccine
Reinforce employee accountability for safety
Renew bloodborne training
Monitor work practices
Renew hazmat training
Work orders written
Ergonomic set-up evaluation
Maintenance work order written
Air quality consultation
Procedures revised
MVA=
Local or
State Investigation
Referrals made
Other
Apply OSHA program and manuals
manaGer sIGnature:
prInt name:
date:
supervIsor sIGnature:
prInt name:
date:
white copy - Agency
pink copy - Agency Human Resources
yellow copy - DAS Human Resources
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Parent category: Business