Form F417-048-000 "Supervisor's Report of an Accident" - Washington

Form F417-048-000 is a Washington State Department of Labor and Industries form also known as the "Supervisor's Report Of An Accident". The latest edition of the form was released in October 1, 2005 and is available for digital filing.

Download an up-to-date Form F417-048-000 in PDF-format down below or look it up on the Washington State Department of Labor and Industries Forms website.

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Download Form F417-048-000 "Supervisor's Report of an Accident" - Washington

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THIS IS YOUR RECORD -- KEEP IN YOUR FILE
SUPERVISOR'S REPORT OF AN ACCIDENT
Name of Injured Employee:___________________________________________________
Date of Report __________________________
Age
Length of Employment
Department
Section
At plant
On job
Head
Hands
Wounds
Amputation
Death
Lost Time
Eyes
Legs
Strain & Sprain
Burns
First Aid Only
Trunk
Toes
Hernia
Foreign Body
Arms
Internal
Fracture
Skin (occupational)
Due to Delayed Medical Treatment
Remarks:________________________
Remarks:______________________________________
Remarks:__________________________
________________________________
______________________________________________
__________________________________
Date of Injury
Hour
Department
Exact Location
Eyewitnesses ________________________________________________________________________________________________________
Describe accident: Include the machine, equipment, object or substance involved . . . . . All Details . . . . . Use back space if necessary
X
O
CAUSE: Mark basic cause
Mark contributing cause, if any
UNSAFE CONDITIONS
UNSAFE ACTS
1
Inadequately Guarded
1
Operating Without Authority
2
Unguarded
2
Operating at Unsafe Speed
3
Defective Tools, Equipment, or Substance
3
Making Safety Devices Inoperative
4
Unsafe Design or Construction
4
Using Unsafe Equipment or Equipment Unsafely
5
Hazardous Arrangement
5
Unsafe Loading, Placing, Mixing
6
Unsafe Illumination
6
Taking Unsafe Position
7
Unsafe Ventilation
7
Working on Moving or Dangerous Equipment
8
Unsafe Clothing
8
Distraction, Teasing, Horse Play
9
Insufficient Instruction
9
Failure to use Personal Protective Devices
Why was the unsafe act committed? ____________________________
Why did the unsafe condition exist? ____________________________
Any physical disabilities? ________________________________________________________________________________________________
Number of previous disablng injuries _______________________________________________________________________________________
GUIDES TO CORRECTIVE ACTION
Based on the cause checked above, I am taking the following corrective action:
UNSAFE ACT
UNSAFE CONDITION
I
f Supervisor Can't Handle, Then
1
Stop the Behavior
1
Remove
(a)
Own Boss, OR
5
Recommend To:
2
Study the Job
2
Guard
(b)
Safety Committee, OR
3
Instruct (tell--show--try--check)
3
Warn
(c)
Maintenance Dept., OR
4
Follow Up
4
Supervisory
(d)
___________________
Training
5
Enforce
6
Follow Up
What I am actually doing to prevent similar injuries____________________________________________________________________________
______________________________________________________________________________________________________________________
What further recommendations? ___________________________________________________________________________________________
SIGNATURES
Immediate Supervisor or Foreman
Received by Plant Manager or Superintendent
DEPARTMENT OF LABOR AND INDUSTRIES
F417-048-000 supervisor's report of an accident 10-05
WISHA SERVICES DIVISION
THIS IS YOUR RECORD -- KEEP IN YOUR FILE
SUPERVISOR'S REPORT OF AN ACCIDENT
Name of Injured Employee:___________________________________________________
Date of Report __________________________
Age
Length of Employment
Department
Section
At plant
On job
Head
Hands
Wounds
Amputation
Death
Lost Time
Eyes
Legs
Strain & Sprain
Burns
First Aid Only
Trunk
Toes
Hernia
Foreign Body
Arms
Internal
Fracture
Skin (occupational)
Due to Delayed Medical Treatment
Remarks:________________________
Remarks:______________________________________
Remarks:__________________________
________________________________
______________________________________________
__________________________________
Date of Injury
Hour
Department
Exact Location
Eyewitnesses ________________________________________________________________________________________________________
Describe accident: Include the machine, equipment, object or substance involved . . . . . All Details . . . . . Use back space if necessary
X
O
CAUSE: Mark basic cause
Mark contributing cause, if any
UNSAFE CONDITIONS
UNSAFE ACTS
1
Inadequately Guarded
1
Operating Without Authority
2
Unguarded
2
Operating at Unsafe Speed
3
Defective Tools, Equipment, or Substance
3
Making Safety Devices Inoperative
4
Unsafe Design or Construction
4
Using Unsafe Equipment or Equipment Unsafely
5
Hazardous Arrangement
5
Unsafe Loading, Placing, Mixing
6
Unsafe Illumination
6
Taking Unsafe Position
7
Unsafe Ventilation
7
Working on Moving or Dangerous Equipment
8
Unsafe Clothing
8
Distraction, Teasing, Horse Play
9
Insufficient Instruction
9
Failure to use Personal Protective Devices
Why was the unsafe act committed? ____________________________
Why did the unsafe condition exist? ____________________________
Any physical disabilities? ________________________________________________________________________________________________
Number of previous disablng injuries _______________________________________________________________________________________
GUIDES TO CORRECTIVE ACTION
Based on the cause checked above, I am taking the following corrective action:
UNSAFE ACT
UNSAFE CONDITION
I
f Supervisor Can't Handle, Then
1
Stop the Behavior
1
Remove
(a)
Own Boss, OR
5
Recommend To:
2
Study the Job
2
Guard
(b)
Safety Committee, OR
3
Instruct (tell--show--try--check)
3
Warn
(c)
Maintenance Dept., OR
4
Follow Up
4
Supervisory
(d)
___________________
Training
5
Enforce
6
Follow Up
What I am actually doing to prevent similar injuries____________________________________________________________________________
______________________________________________________________________________________________________________________
What further recommendations? ___________________________________________________________________________________________
SIGNATURES
Immediate Supervisor or Foreman
Received by Plant Manager or Superintendent
DEPARTMENT OF LABOR AND INDUSTRIES
F417-048-000 supervisor's report of an accident 10-05
WISHA SERVICES DIVISION
1.
Describe the accident in your own words just as you saw it happen. Describe the surroundings or setting before the accident and the
position of the injured party in relation to the surroundings, then describe the steps in proper sequence leading to the accident that
happened. If possible attach a picture or make a drawing.
2.
Describe any near accidents you have observed in the past week.
3.
Report any unsafe procedures you have observed in the past week. (Physical hazards are classed as unsafe procedures as well as human acts.)
F417-048-000 supervisor's report of an accident 10-05
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