Accident Investigation Report v 1.

0
Effective Date: Date for Review:
Supervisor Form
August 15, 2023 August 15, 2024

INSTRUCTIONS

Complete this form as soon as possible after an incident that results in serious injury or
illness. (Optional: Use to investigate a minor injury or near miss that could have resulted in a
serious injury or illness.)

EMPLOYEE INFORMATION

Name of Injured Employee:

Date of Birth: Gender:

Phone Number:

Address:

Position and Department:

Status: ☐ Regular Full-Time   ☐ Regular Part-Time ☐ Seasonal ☐ Temporary

INCIDENT DETAILS

Date: Time:

Location:

Type of Report: ☐ Injury   ☐ Illness   ☐ Near Miss

☐ Entering or Exiting Work
☐ During Normal Work Activities
☐ During Meal Period
Part of Workday:
☐ During Break
☐ Working Overtime
☐ Other:

Accident Investigation Report – Supervisor Form Page 1 of 6

 Accident Investigation Report v 1.0
Effective Date: Date for Review:
Supervisor Form
August 15, 2023 August 15, 2024

Witnesses (if any):

Describe fully, step-by-step how the accident happened. What was the employee doing prior
to the event? What equipment, tools, and personal protection equipment were being used?
(Continue on back if needed)

What caused the event?

Were safety regulations in place and used? If not, what was wrong?

Accident Investigation Report – Supervisor Form Page 2 of 6

 Accident Investigation Report v 1.0
Effective Date: Date for Review:
Supervisor Form
August 15, 2023 August 15, 2024

MEDICAL ATTENTION

Was a doctor consulted about this incident? ☐ Yes, see below   ☐ No  

Date: Time:

Treating Physician:

Phone Number:

NATURE OF INJURY

☐ Abrasion, scrapes ☐ Crushing Injury

☐ Amputation ☐ Cut, laceration, puncture
☐ Broken bone ☐ Hernia
☐ Bruise ☐ Illness
☐ Burn (heat) ☐ Sprain, strain
☐ Burn (chemical) ☐ Damage to a body system:
☐ Concussion (to the head) ☐ Other: ____________________________

Part of Body Affected (circle all that apply)

Accident Investigation Report – Supervisor Form Page 3 of 6

 Accident Investigation Report v 1.0
Effective Date: Date for Review:
Supervisor Form
August 15, 2023 August 15, 2024

/
UNSAFE WORKPLACE CONDITIONS

☐ Inadequate guard ☐ Lack of needed personal protective

☐ Unguarded hazard equipment

☐ Safety device is defective ☐ Lack of appropriate equipment or tools

☐ Tool or equipment defective ☐ Unsafe clothing
☐ Workstation layout is hazardous ☐ No training or insufficient training
☐ Unsafe lighting ☐ Other:
☐ Unsafe ventilation ____________________________________

UNSAFE ACTS BY PEOPLE

☐ Operating without permission ☐ Taking an unsafe position or posture

☐ Operating at unsafe speed ☐ Distraction, teasing, horseplay
☐ Servicing equipment with power to it ☐ Failure to wear personal protective
☐ Making a safety device inoperative equipment

☐ Using defective equipment ☐ Failure to use the available equipment or

tools
☐ Using equipment in an unapproved way

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 Accident Investigation Report v 1.0
Effective Date: Date for Review:
Supervisor Form
August 15, 2023 August 15, 2024

☐ Unsafe lifting ☐ Other:

_____________________________________

Why did the unsafe conditions exist?

Why did the unsafe acts occur?

Is there a reward (such as “the job can be done more quickly”, or “the product is less likely to
be damaged”) that may have encouraged the unsafe conditions or acts?
☐ Yes, describe below ☐ No

Were the unsafe acts or conditions reported prior to the incident? ☐ Yes ☐ No
Have there been similar incidents or near misses prior to this one? ☐ Yes ☐ No
What changes do you suggest to prevent this incident/near miss from happening again?

☐ Stop this activity ☐ Write a new policy/rule

☐ Guard the hazard ☐ Enforce existing policy
☐ Train the employee(s) ☐ Routinely inspect for the hazard
☐ Train the supervisor(s) ☐Personal Protective Equipment
☐ Redesign task steps ☐ Other:
☐ Redesign work station ____________________________________
What should be (or has been) done to carry out the suggestion(s) checked above?

Accident Investigation Report – Supervisor Form Page 5 of 6

 Accident Investigation Report v 1.0
Effective Date: Date for Review:
Supervisor Form
August 15, 2023 August 15, 2024

Attachments (write number of attachments in space provided)

Written Witness Statements Photographs Maps/drawings

Name & Title of Supervisor

Preparing this Report
Names of Others on
Investigation Team

Supervisor Date Reviewer Date

Signature over Printed Name Signature over Printed Name

Accident Investigation Report – Supervisor Form Page 6 of 6