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Supervisor's Report of Work Injury (United States)

This is a supervisor's report of a work injury. The form provided here is simply a sample of what the actual form looks like.

SUPERVISOR'S REPORT OF WORK INJURY

Date of Report _________________

Injured Employee ________________________________

Age ______

Job Title ______________________

Employee Number ___________

Location ______________________

Department ________________

Date of Hire ___________________

Time in this job (months) ______

Time on this shift (months) ____________

Date of Injury _____________________

Time of Injury ______

Exact Location ___________________________________________

Names of Witnesses _______________________

Injury to:

[___] Face or Head [___] Legs [___] Eyes [___] Toes or Foot [___] Body

[___] Internal [___] Arms [___] Lungs [___] Hands or Fingers

[___] Other ___________________

Type of Injury:

[___] Lacerations [___] Amputation [___] Strain or Sprain [___] Burns [___] Hernia

[__] Foreign Body [___] Fracture [___] Skin [___] Puncture [___] Gas

[___] Abrasion [___] Other ______________

Treatment:

[___] First Aid [___] Nurse [___] Doctor's Care [___] Serious [___] Lost time

[___] Fatality

Remarks: Be specific (L or R arm, etc.) __________________________

Describe how employee was injured: (What was employee doing? What duty or task?)

____________________________________________________________

What happened that resulted in this injury? (Examples: slipped, fell, was struck)

___________________________________________________________

What factors do you believe contributed to this accident? (Consider methods, procedures, tools, machines, equipment arrangements, instructions, rules, inherent hazards, skill, experience, materials, and other factors.)

_________________________

How could such an accident have been prevented or avoided?

___________________________________________________________

The investigating Committee (People to be included in the accident investigation are listed below.)

1. Injured Employee ______________________________________

2. Immediate Supervisor ___________________________________

3. Safety Committee person _________________________________

4. Shop Steward _________________________________________

5. Department Head (or Rep.) _______________________________

6. Witnesses ____________________________________________

7. Safety Dept. Representative _______________________________

8. Designated Union Safety Rep. ______________________________

9. Manager or Appointed Rep. _______________________________

Note: Report to be completed by immediate supervisor and turned in to the Safety Department no later than the end of the day following the injury. All lost time injuries or fatalities must be promptly reported.

Important: All fatalities or accidents resulting in five or more persons being hospitalized must be reported to the appropriate federal or state agency enforcing OSHA regulations within the time limits applicable.

PEOPLE TO BE INCLUDED IN ACCIDENT INVESTIGATIONS:

Near Miss/No Injury _______________________________

The extent of the investigation will be left to the discretion of the supervisor.

_______________________________

Slight (First Aid) _______________________________

Immediate Investigation

1. Injured Employee _______________________________

2. Immediate Supervisor _______________________________

Nurse Case

Immediate Investigation

1. Injured Employee _______________________________

2. Immediate Supervisor _______________________________

3. Safety Committee person _______________________________

Doctor Case

Immediate Investigation

1. Injured Employee _______________________________

2. Immediate Supervisor _______________________________

3. Safety Committee person _______________________________

4. Shop Steward _______________________________

5. Department Head (or Rep.) _______________________________

6. Witnesses _______________________________

Final Investigation

1. Injured Employee _______________________________

2. Immediate Supervisor _______________________________

3. Safety Committee person _______________________________

4. Shop Steward _______________________________

5. Department Head (or Rep.) _______________________________

6. Witnesses _______________________________

7. Safety Dept. Representative Lost Time or Fatality

_______________________________

Immediate Investigation

1. Injured Employee _______________________________

2. Immediate Supervisor _______________________________

3. Safety Committee person _______________________________

4. Shop Steward _______________________________

5. Department Head (or Rep.) _______________________________

6. Witnesses _______________________________

7. Safety Dept. Representative _______________________________

8. Designated Union Safety Rep. _______________________________

Final Investigation

1. Injured Employee _______________________________

2. Immediate Supervisor _______________________________

3. Safety Committee person _______________________________

4. Shop Steward _______________________________

5. Department Head (or Rep.) _______________________________

6. Witnesses _______________________________

7. Safety Dept. Representative _______________________________

8. Designated Union Safety Rep. _______________________________

9. Manager or Appointed Rep. _______________________________

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