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Workplace Injury Investigation Report

This incident report summarizes a workplace injury involving an employee. It documents the employee's name and age, occupation, date and time of the incident, location, witnesses, and whether first aid or medical treatment was authorized. It also notes if the employee left or returned to work and when. The report describes the nature and extent of the employee's injuries as well as the incident itself. Potential causes of the accident are marked including issues with equipment, environment, behaviors, and protections. Recommended actions to prevent future occurrences are provided. The report requires signatures from the supervisor, safety responsible person, and manager.

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76 views2 pages

Workplace Injury Investigation Report

This incident report summarizes a workplace injury involving an employee. It documents the employee's name and age, occupation, date and time of the incident, location, witnesses, and whether first aid or medical treatment was authorized. It also notes if the employee left or returned to work and when. The report describes the nature and extent of the employee's injuries as well as the incident itself. Potential causes of the accident are marked including issues with equipment, environment, behaviors, and protections. Recommended actions to prevent future occurrences are provided. The report requires signatures from the supervisor, safety responsible person, and manager.

Uploaded by

Nido Vensra
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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Supervisor’s Incident Investigation Report

for Workplace Injuries

1. Name of employee Age


2. Occupation Dept. & No.
3. Date of incident Time A.M. P.M.
4. Place of incident
5. Witness(es)
6. Did you authorize first-aid or doctor? 00 Yes 00 No
Name and address of doctor
7. Did injured leave work? 00 Yes 00 No When
8. Did injured return to work? 00 Yes 00 No When
9. Describe nature and extent of injuries
10. Describe incident
11. Accident causes (mark those that apply)

Physical Sources
Unsafe behaviors
00 Poorly maintained tools or equipment
00 Poor housekeeping, slippery floor, or 00 Inadequate instructions
tripping hazards 00 Did not use assigned personal protective
00 Unguarded equipment equipment
00 Crowded work conditions 00 Did not follow rules or instructions
00 Poor storage practices 00 Circumvented safety features
00 Used poorly maintained tools and machinery
00 Personal protection and clothing not
00 Failed to follow established procedures and
adequate for hazards
work practices
00 Insufficient lighting or ventilation
00 Unable to physically perform work
00 Cold or hot temperatures 00 Other contributing behaviors
00 Other contributing conditions

12. Describe actions to take to avoid recurrence:

13. Signatures:

14. Prepared By:


(Supervisor)
Reviewed By:
(Person Responsible for Safety)

(Manager)
Date:
(Must be completed within 24 hours of incident)
- Company Use Only -

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