"Supervisor's Injury Report" - Montana

Supervisor's Injury Report is a legal document that was released by the Montana Department of Livestock - a government authority operating within Montana.

Form Details:

  • Released on July 1, 2020;
  • The latest edition currently provided by the Montana Department of Livestock;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of the form by clicking the link below or browse more documents and templates provided by the Montana Department of Livestock.

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SUPERVISOR’S INJURY REPORT 
 
Date of injury: ______ Time of injury: _____________ Date and time of investigation:  
 
 
WHO was injured: _____________________________________________________________ 
 
 
WHO else was involved in the incident: ____________________________________________ 
 
 
WHO witnessed the incident: ____________________________________________________ 
 
____________________________________________________________________________ 
 
 
WHAT was the employee doing when injured? 
 
 
 
 
 
 
WHAT equipment, process or activity not described above may be related to the incident? 
 
 
 
 
 
 
WHERE did the incident take place? 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
WHAT is the specific injury? (include body part(s) and severity) 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
‐continued on back‐ 
July 2020 
SUPERVISOR’S INJURY REPORT 
 
Date of injury: ______ Time of injury: _____________ Date and time of investigation:  
 
 
WHO was injured: _____________________________________________________________ 
 
 
WHO else was involved in the incident: ____________________________________________ 
 
 
WHO witnessed the incident: ____________________________________________________ 
 
____________________________________________________________________________ 
 
 
WHAT was the employee doing when injured? 
 
 
 
 
 
 
WHAT equipment, process or activity not described above may be related to the incident? 
 
 
 
 
 
 
WHERE did the incident take place? 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
WHAT is the specific injury? (include body part(s) and severity) 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
‐continued on back‐ 
July 2020 
 
WHY did this injury occur to this person at this time? Describe immediate cause and all underlying (root) 
causes you can identify. Continue to ask “why” for at least 5 levels of identified causes. 
 
1. 
 
 
 
2. 
 
 
 
3. 
 
 
 
4. 
 
 
 
5. 
 
 
 
HOW can similar incidents be prevented in the future? (include management, employee, equipment, 
and environmental considerations) 
 
 
 
 
 
 
 
 
Name and title of person completing form:________________________________________________       
 
Phone :____________________________ 
 
Signature: ___________________________________________________________________ 
 
 
 
Safety Follow‐up: What preventive measures were put in place to permanently avoid recurrence of 
similar incidents 
July 2020 
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