DRS Supervisor's Incident Report

• Office Location

• Conducted on

  Date

• Prepared by

• Location
  Address

• Required to be completed when there is workplace incident (auto or worker's compensation).
  Completed forms should be email to claims@drsinstall.com within 24 hours of the incident.

Incident Type

• What type of incident was this? (Auto, Worker's Comp.)

  Auto

  Worker's Comp

• Employee's Name

• Date and time of the incident

  Date

• Location of the incident

• Were you contacted and notified on the day of the incident?

  Yes

  No

  N/A

• Date and time notified

  Date

• Why wasn't the injury reported the day of the incident?

• Did you travel to the incident location?

  Yes

  No

  N/A

• How many miles did you travel?

• What time did you arrive?

• Why didn't you travel to the incident?

Work Related Injury

• What part of the body was injured?

• What was the nature of the injury? (laceration, puncture, break, strain, bite, rash, etc.)

• Why did the employee do what they did?

• Was medical treatment requested?

  Yes

  No

  N/A

• Were they taken or directed to go?

  Taken by supervisor

  Directed to go

  Taken by ambulance

• Where was the technician taken for medical treatment?

• Complete a DRS Declination of Treatment form on iAuditor and email to claims@drsinstall.com.

• Was equipment, tools, or PPE involved in this injury?

  Yes

  No

  N/A

• What equipment or tools were used?

• Were they used correctly?

• Was regular maintenance of the equipment carried out?

Auto Incident

• Was the employee injured in the auto incident?

  Yes

  No

  N/A

• Fill out the section in the Work Related Injury Category.

• Was anyone else injured?

  Yes

  No

  N/A

• List the names of the injured, their injury, and contact information

• How were they transported and where?

Incident Information

• Describe in full how the incident happened.

• What other factors contributed to this incident (weather, lighting, accessibility, condition of property, temperature, etc.)?

• Were Safety policies and procedures followed?

  Yes

  No

  N/A

• Explain what unsafe acts or conditions were not followed.

• Were the safety rules communicated to and understood by the employee?

• Had this hazard been previously identified?

• What is your recommendation for preventative action to take in the future to prevent repeating this incident?

• Was disciplinary action taken, if needed?

  Yes

  No

  N/A

• What disciplinary action was taken?

• Any observations, comments, or concerns about this incident after you completed your investigation?

• Supervisor's Signature

  Sign

• This completed form should be emailed to claims@drsinstall.com within 24 hours of the incident.