INCIDENT REPORT

Date

Employee Name Stock #

Was there another vehicle involved? if so, last 8 of VIN

Was there other individuals involved? if so, Name of Persons

Insurance company Policy #

Were the police called? if so, Police Report #

What happened (who, what, when, where, why, and how)?

Add'l Comments:

Employee Signature Manager Signature

 INCIDENT INVESTIGATION REPORT
NAME AGE TIME DATE

DEPARTMENT CLAIM # JOB HOW LONG AT THIS JOB

WHAT HAPPENED? (Describe how the incident occurred.)

WHY DID IT HAPPEN? (Answer the following: Why, What, Where, When, Who, How)

WHAT SHOULD BE DONE TO PREVENT A REOCCURRENCE? (Eliminate the unsafe acts, unsafe conditions, or both,
which caused the incident. Not carelessness or stupidity.)

WHAT ACTION HAS BEEN TAKEN & WHAT ACTION NEEDS TO BE TAKEN? (Take or recommend action depending
upon your authority.)

WHEN WILL ALL CORRECTIVE ACTION BE COMPLETED? (Recommend a target date for corrective action. Will the
action eliminate the loss cause?)

COMMENTS:

INVESTIGATED BY: DATE REVIEWED BY: DATE

 SUPERVISOR'S ACCIDENT REPORT
This report is to be filled out before the end of the shift during which the accident or illness occurred. It
must be accompanied by the "EMPLOYERS REPORT OF ACCIDENT" FORM and Coding Sheet with
all three to the Safety Coordinator ASAP, and forwarded to WRS.
FACILITY:

NAME OF PERSON INJURED:

EMPLOYMENT STATUS (CIRCLE ONE) : FULL TIME PART- TIME VOLUNTEER

EXACT LOCATION OF ACCIDENT

WAS ACCIDENT SITE REVIEWED BY SUPERVISOR: YES NO

DID SUPERVISOR INTERVIEW INJURED PERSON: YES NO

DID SUPERVISOR INTERVIEW WITNESSES: YES NO

EXACTLY HOW DID ACCIDENT OCCUR? DESCRIBE PERSONS, ACTION, EQUIPMENT, CONDITIONS, ETC. :

WAS EMPLOYEE WEARING/ USING REQUIRED SAFETY EQUIPMENT? YES NO N/A

WHAT EQUIPMENT COULD HAVE BEEN UTILIZED TO PREVENT THIS ACCIDENT:

IS THIS EQUIPMENT AVAILABLE FOR EMPLOYEE USE? YES NO

RANK ON A SCALE OF 1-4 HOW THE FOLLOWING FACTORS COULD BE IMPROVED TO HELP PREVENT THIS
ACCIDENT, WITH 1 BEING THE FACTOR NEEDING MOST IMPROVEMENT:

TRAINING:

COMMUNICATIONS:

POLICIES/ PROCEDURES:

INSPECTIONS:
SPECIFICALLY INDICATE WHAT ACTIONS/ MEASURES ARE NEEDED TO IMPROVE THE TWO TOP AREAS
RANKED 1 AND 2 ABOVE:

WHAT IMMEDIATE ACTION HAS BEEN TAKEN TO PREVENT THE RECURRENCE OF A SIMILAR ACCIDENT?
 REPORT BY EYEWITNESS

NAME OF EMPLOYER:

NAME OF INJURED EMPLOYEE:

NAME OF WITNESS: WITNESS PHONE:

WITNESS ADDRESS:

DATE OF INCIDENT:

IN YOUR OWN WORDS, DESCRIBE WHAT YOU SAW HAPPEN:

DID ANYONE ELSE SEE THE ACCIDENT?

IF YES, PLEASE LIST THEIR NAMES:

OTHER COMMENTS:

DATE SIGNATURE OF WITNESS

 REPORT BY INJURED EMPLOYEE

EMPLOYER:

YOUR NAME:

YOUR HOME ADDRESS:

YOUR HOME PHONE NUMBER: AGE:

SOCIAL SECURITY NUMBER:

DATE OF ACCIDENT: TIME OF ACCIDENT:

IN YOUR OWN WORDS, PLEASE DESCRIBE WHAT HAPPENED:

WHAT PHYSICAL PROBLEMS DO YOU RELATE TO THIS INJURY?

DID YOU REPORT THIS INJURY TO YOUR SUPERVISOR?

IF NOT, WHY NOT?

DATE REPORTED: SUPERVISOR'S NAME:

WERE YOU WORKING AT YOUR REGULAR JOB AT THE TIME OF THE INJURY?

IF NOT, PLEASE EXPLAIN:

WERE THERE ANY WITNESSES? IF YES, WHO?

ANY ADDITIONAL COMMENTS:

DATE: SIGNATURE:
 WORKERS' COMPENSATION CODING SHEET

DATE:

EMPLOYEE NAME: DATE OF ACCIDENT:

EMPLOYER NAME:

CAUSE CODES: BODY PART INJURED:

□ 01. FALL, TRIP, SLIP □ 01. HAND/ FINGER
□ 02. AUTO ACCIDENT □ 02. BACK
□ 03. REPETITIVE MOTION □ 03. ARM/ WRIST
□ 04. MATERIAL IN EYE □ 04. SHOULDER
□ 05. OVEREXERTION □ 05. FOOT
□ 06. STRUCK BY OBJECT □ 06. LEG/ ANKLE/ KNEE
□ 07. INJURED BY OTHER PERSON □ 07. EYE
□ 08. BURN FROM HEAT/ CHEMICALS □ 08. HEAD/ TEETH/ EAR
□ 09. LACERATION □ 09. NECK
□ 99. OTHER □ 10. TRUNK/ HIP/ CHEST
□ 11. OTHER
DATE OF WEEK: TIME OF DAY:
□ 01. SUNDAY □ 01. 1:00 a.m.
□ 02. MONDAY □ 02. 2:00 a.m
□ 03. TUESDAY □ 03. 3:00 a.m.
□ 04. WEDNESDAY □ 04. 4:00 a.m.
□ 05. THURSDAY □ 05. 5:00 a.m.
□ 06. FRIDAY □ 06. 6:00 a.m.
□ 07. SATURDAY □ 07. 7:00 a.m
□ 08. 8:00 a.m.
LENGTH OF EMPLOYMENT: □ 09. 9:00 a.m.
□ 01. 0-30 DAYS □ 10. 10:00 a.m
□ 02. 31-90 DAYS □ 11. 11:00 a.m.
□ 03. 91-180 DAYS □ 12. 12:00 Noon
□ 04. 6 MONTHS TO 1 YEAR □ 13. 1:00 p.m.
□ 05. 1 YEAR TO 3 YEARS □ 14. 2:00 p.m.
□ 06. GREATER THAN 3 YEARS □ 15. 3:00 p.m.
□ 16. 4:00 p.m.
DEPARTMENT: □ 17. 5:00 p.m.
□ 01. NEW CAR/ TRUCK SALES □ 18. 6:00 p.m.
□ 02. USED CAR/ TRUCK SALES □ 19. 7:00 p.m.
□ 03. SERVICE □ 20. 8:00 p.m.
□ 04. PARTS □ 21. 9:00 p.m.
□ 05. BODY SHOP □ 22. 10:00 p.m.
□ 06. BUSINESS □ 23. 11:00 p.m.
□ 07. F & I □ 24. 12:00 Midnight
□ 99. OTHER