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. _______________________________