ATTACHMENT C

Yansab
SUPERVISOR'S INCIDENT/INJURY/ILLNESS INVESTIGATION REPORT
COMPANY LOCATION/AREA

SUPERVISOR DATE/TIME

INJURY PROPERTY DAMAGE NEAR MISS

DESCRIPTION OF INJURY

INJURED NAME I.D. BADGE #

EQUIPMENT/PROPERTY DAMAGE

DESCRIPTION OF INCIDENT

INVESTIGATION RESULTS

WITNESS COULD INJURY HAVE BEEN PREVENTED ?

YES

NO

ACTIVITY AT TIME OF INCIDENT

PROCEDURE VIOLATION

DEFECTIVE EQUIPMENT/MATERIAL
NONE

DISCIPLINE
Considered, but not warranted

WHAT MANAGEMENT CONTROL OR PROCESS WEAKNESS ALLOWED THIS INCIDENT TO OCCUR AND WHAT IS GOING TO BE
DONE TO IDENTIFY AND CORRECT THIS WEAKNESS

RECOMMENDATIONS

05c-Supvervisor-Invest-Report.xls