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SUPERVISOR'S INCIDENT INVESTIGATION REPORT
To be completed the same day of incident or date notified of incident
General Information
1. Location (Store-Branch-Project-Job)
Address
Job Number
2. Date of Occurrence
3. Time
4. Date Notified
5. Date Report Completed
6. Customer
FORM "A" — Injury or Illness
7. Employee Name
Employee ID
8. Address
9. Phone
10. Relationship to Company
11. Occupation / Dept
12. Severity
First Aid Only
Disabling
Non Disabling
Fatal
FORM "B" — Property Damage or Other
13. Name
14. Address
15. Phone
16. Nature of Damage or Loss
17. Amount of Damage - Estimate Repair Cost
Description
18. Describe Injury or Damage - Describe clearly how incident occurred
19. Medical Treatment - Doctor (Name/Phone)
Hospital
Analysis
20. What acts, conditions, or failure to act, contributed most directly to this incident?
21. Check all that apply — basic or fundamental reason(s) for the existence of acts or conditions
Unsafe Method/Misuse
Unsafe Condition or Equip
Improper Instruction
Poor Housekeeping
Insufficient Employee Training
Inadequate Supervision
Physical/Mental Condition
Inoperative Safety Device
Protective Equip Not Used
Work Procedure Violation
Unnecessary Haste
Day Dreaming/Inattention
Poor Judgment
Improper Dress
Horseplay
Improper Maintenance
Unsafe Process
Poor Ventilation
Improper Guarding
Other
If Other, describe:
Action
22. What action has been or will be taken to prevent recurrence?
Signatures
Supervisor Name
Date
23. Review in Home Office By
Submit Report
