AUBREY SILVEY
ENTERPRISES, INC.
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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
Number
2. Date of Occurrence
3. Time
AM / PM
AM
PM
4. Date Notified
5. Date Report Completed
FORM "A" — Injury or Illness
6. Name
7. Address
8. Phone
9. Relationship to Company
10. Occupation / Dept
11. Severity
First Aid Only
Disabling
Non Disabling
Fatal
FORM "B" — Property Damage or Other
12. Name
13. Address
14. Phone
15. Nature of Damage or Loss
16. Amount of Damage - Estimate Repair Cost
Description
17. Describe Injury or Damage - Describe clearly how incident occurred
18. Medical Treatment - Doctor (Name/Phone)
Hospital
Analysis
19. What acts, conditions, or failure to act, contributed most directly to this incident?
20. Check the basic or fundamental reasons 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
21. What action has been or will be taken to prevent recurrence?
Signatures
Supervisor Name
Date
22. Review in Home Office By
Submit Report