"Supervisor's Accident Report Template"

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SUPERVISOR’S REPORT OF ACCIDENT
This form should be completed by the supervisor as soon after a work accident as possible. It is useful in gathering information for investigating accidents and their
causes so that corrective action can be taken and future accidents avoided. Every accident should be investigated and the causes corrected.
Name of Employee: ____________________________ City/City Organization: ________________________________ Dept.: _______________________________
Date of Accident: _______________________ Time of Accident: ____________________ Did employee lose time from work?
YES
NO
Hours lost on day of accident: ______________________________________ Has employee returned to work?
YES
NO
Employee’s job title: ___________________________________________ Years of employee’s service with City/City organization: ________________
Years employee has been in present job: _______________________
Number of hours employee works per week: ____________________________
GIVE US YOUR HONEST COMMENTS ON QUESTIONS BELOW. WE ARE NOT TRYING TO
BLAME ANYONE. YOUR OPINION MAY HELP US PREVENT ACCIDENT REPETITION.
CHECK “YES” OR “NO”
PLEASE ANSWER THE FOLLOWING:
HAD INJURED PERSON BEEN PROPERLY INSTRUCTED IN SAFE AND EFFICIENT METHODS? ……………… YES
1.
NO
DID INJURED PERSON VIOLATE ANY INSTRUCTIONS? …………………………………………………………….. YES
2.
NO
WAS NECESSARY PROTECTIVE EQUIPMENT WORN? (IF APPLICABLE) ………………………………………… YES
3.
NO
DID POOR HOUSKEEPING CONTRIBUTE TO INJURY? ……………………………………………………………….. YES
4.
NO
DID HORSEPLAY CAUSE THE INJURY? ……………………………………………………………………………..
5.
YES
NO
WAS INJURY CAUSED BY SOMETHING THAT NEEDED REPAIRS? ……………………………………………...
6.
YES
NO
SHOULD A GUARD BE PROVIDED? ……………………………………………………………………………………… YES
7.
NO
DID ANY BODILY DEFECT CONTRIBUTE TO INJURY? ………………………………………………………………. YES
8.
NO
WAS INJURY CAUSED BY AN UNSAFE ACT? ………………………………………………………………………… YES
9.
NO
DID INJURED REPORT THE INJURY TO YOU, THE SUPERVISOR, IMMEDIATELY? ……………………………… YES
10.
NO
ACCIDENT. (Describe what the injured employee was doing at the time of the accident, what happened, who was involved, nature of the injury.) ________________
______________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________
Witnesses’ Names _______________________________________________________________________________________________________________________
UNSAFE ACTS. (Did the injured employee or another person do something incorrectly?) _____________________________________________________________
______________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________
UNSAFE CONDITIONS. (What unguarded or unsafe condition of machinery, equipment, building or premises was involved?) ______________________________
______________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________
ACTIONS TAKEN. (After the injury, what did the employer do to correct the conditions that caused the injury?) ________________________________________
______________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________
REMEDIES. (What should the employer do to prevent other injuries like this?) _____________________________________________________________________
______________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________
MEDICAL CARE. Did the employee go to the Doctor or Hospital?
YES
NO
If yes, please complete the following:
Name of Doctor or Hospital: _____________________________________________________ Date of initial visit: ___________________________
Address: ___________________________________________________________________________ Telephone number: ____________________________
AS SUPERVISOR, DO YOU FEEL THAT THIS INJURY SHOULD BE COVERED UNDER WORKERS’ COMPENSATION?
YES
NO
Reasons why or why not: _________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________
Report Submitted By: ________________________________________________________________________ Date: _______________________________________
SUPERVISOR’S REPORT OF ACCIDENT
This form should be completed by the supervisor as soon after a work accident as possible. It is useful in gathering information for investigating accidents and their
causes so that corrective action can be taken and future accidents avoided. Every accident should be investigated and the causes corrected.
Name of Employee: ____________________________ City/City Organization: ________________________________ Dept.: _______________________________
Date of Accident: _______________________ Time of Accident: ____________________ Did employee lose time from work?
YES
NO
Hours lost on day of accident: ______________________________________ Has employee returned to work?
YES
NO
Employee’s job title: ___________________________________________ Years of employee’s service with City/City organization: ________________
Years employee has been in present job: _______________________
Number of hours employee works per week: ____________________________
GIVE US YOUR HONEST COMMENTS ON QUESTIONS BELOW. WE ARE NOT TRYING TO
BLAME ANYONE. YOUR OPINION MAY HELP US PREVENT ACCIDENT REPETITION.
CHECK “YES” OR “NO”
PLEASE ANSWER THE FOLLOWING:
HAD INJURED PERSON BEEN PROPERLY INSTRUCTED IN SAFE AND EFFICIENT METHODS? ……………… YES
1.
NO
DID INJURED PERSON VIOLATE ANY INSTRUCTIONS? …………………………………………………………….. YES
2.
NO
WAS NECESSARY PROTECTIVE EQUIPMENT WORN? (IF APPLICABLE) ………………………………………… YES
3.
NO
DID POOR HOUSKEEPING CONTRIBUTE TO INJURY? ……………………………………………………………….. YES
4.
NO
DID HORSEPLAY CAUSE THE INJURY? ……………………………………………………………………………..
5.
YES
NO
WAS INJURY CAUSED BY SOMETHING THAT NEEDED REPAIRS? ……………………………………………...
6.
YES
NO
SHOULD A GUARD BE PROVIDED? ……………………………………………………………………………………… YES
7.
NO
DID ANY BODILY DEFECT CONTRIBUTE TO INJURY? ………………………………………………………………. YES
8.
NO
WAS INJURY CAUSED BY AN UNSAFE ACT? ………………………………………………………………………… YES
9.
NO
DID INJURED REPORT THE INJURY TO YOU, THE SUPERVISOR, IMMEDIATELY? ……………………………… YES
10.
NO
ACCIDENT. (Describe what the injured employee was doing at the time of the accident, what happened, who was involved, nature of the injury.) ________________
______________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________
Witnesses’ Names _______________________________________________________________________________________________________________________
UNSAFE ACTS. (Did the injured employee or another person do something incorrectly?) _____________________________________________________________
______________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________
UNSAFE CONDITIONS. (What unguarded or unsafe condition of machinery, equipment, building or premises was involved?) ______________________________
______________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________
ACTIONS TAKEN. (After the injury, what did the employer do to correct the conditions that caused the injury?) ________________________________________
______________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________
REMEDIES. (What should the employer do to prevent other injuries like this?) _____________________________________________________________________
______________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________
MEDICAL CARE. Did the employee go to the Doctor or Hospital?
YES
NO
If yes, please complete the following:
Name of Doctor or Hospital: _____________________________________________________ Date of initial visit: ___________________________
Address: ___________________________________________________________________________ Telephone number: ____________________________
AS SUPERVISOR, DO YOU FEEL THAT THIS INJURY SHOULD BE COVERED UNDER WORKERS’ COMPENSATION?
YES
NO
Reasons why or why not: _________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________
Report Submitted By: ________________________________________________________________________ Date: _______________________________________