Supervisors Report Of An Accident
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1
2THIS IS YOUR RECORD -- KEEP IN YOUR FILE
SUPERVISOR'S REPORT OF AN ACCIDENT
Name of Injured Employee:___________________________________________________
Date of Report __________________________
Age
Length of Employment
Department
Section
At plant
On job
Head
Hands
Wounds
Amputation
Death
Lost Time
Eyes
Legs
Strain & Sprain
Burns
First Aid Only
Trunk
Toes
Hernia
Foreign Body
Arms
Internal
Fracture
Skin (occupational)
Due to Delayed Medical Treatment
Remarks:________________________
Remarks:______________________________________
Remarks:__________________________
________________________________
______________________________________________
__________________________________
Date of Injury
Hour
Department
Exact Location
Eyewitnesses ________________________________________________________________________________________________________
Describe accident: Include the machine, equipment, object or substance involved . . . . . All Details . . . . . Use back space if necessary
X
O
CAUSE: Mark basic cause
Mark contributing cause, if any
UNSAFE CONDITIONS
UNSAFE ACTS
1
Inadequately Guarded
1
Operating Without Authority
2
Unguarded
2
Operating at Unsafe Speed
3
Defective Tools, Equipment, or Substance
3
Making Safety Devices Inoperative
4
Unsafe Design or Construction
4
Using Unsafe Equipment or Equipment Unsafely
5
Hazardous Arrangement
5
Unsafe Loading, Placing, Mixing
6
Unsafe Illumination
6
Taking Unsafe Position
7
Unsafe Ventilation
7
Working on Moving or Dangerous Equipment
8
Unsafe Clothing
8
Distraction, Teasing, Horse Play
9
Insufficient Instruction
9
Failure to use Personal Protective Devices
Why was the unsafe act committed? ____________________________
Why did the unsafe condition exist? ____________________________
Any physical disabilities? ________________________________________________________________________________________________
Number of previous disablng injuries _______________________________________________________________________________________
GUIDES TO CORRECTIVE ACTION
Based on the cause checked above, I am taking the following corrective action:
UNSAFE ACT
UNSAFE CONDITION
I
f Supervisor Can't Handle, Then
1
Stop the Behavior
1
Remove
(a)
Own Boss, OR
5
Recommend To:
2
Study the Job
2
Guard
(b)
Safety Committee, OR
3
Instruct (tell--show--try--check)
3
Warn
(c)
Maintenance Dept., OR
4
Follow Up
4
Supervisory
(d)
___________________
Training
5
Enforce
6
Follow Up
What I am actually doing to prevent similar injuries____________________________________________________________________________
______________________________________________________________________________________________________________________
What further recommendations? ___________________________________________________________________________________________
SIGNATURES
Immediate Supervisor or Foreman
Received by Plant Manager or Superintendent
DEPARTMENT OF LABOR AND INDUSTRIES
F417-048-000 supervisor's report of an accident 10-05
WISHA SERVICES DIVISION
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