(SIR) Supervisor Injury Report (SIR)

• Reporting Supervisor's Name

• Reporting Supervisor's Employee Number

Employee Information

• Name of Involved or Injured Cast Member

• Cast Member Number of Involved or Injured Cast Member

• Department of Involved or Injured Cast Member

• Position of Involved or Injured Cast Member

DETAILS OF INJURY, IF APPLICABLE

• Date and time of incident

  Date

• Date and time incident was reported.

  Date

• To whom was the incident first reported?

• Building or Area of Park where incident occurred.

• Specific location of incident (for example "in front of sink" or "at unload platform."

• Picture of specific location of accident.

  Media

• How did this accident happen? (State specific job being done, machinery, tools, or objects involved and factors contributing to the accident.)

• Were there any witness(es)? If yes, provide name(s).

  Yes

  No

  N/A

• Nature of injury.

• Part of body.

• Were mechanical guards or other safe guards provided?

  Yes

  No

  N/A

• Was employee using them?

  Yes

  No

  N/A

• Was the employee trained and/or authorized to be using any equipment involved in this incident?

  Yes

  No

  N/A

• Was the employee trained and/or authorized to be performing the job duties that they were doing at the time of the incident?

  Yes

  No

  N/A

ANALYSIS

• Contributing (underlying) Factors:

• Contributing factors photo:

  Media

• What was the potential for severity?

  Minor

  Serious

  Major

• What could have potentially happened?

• What is the probability of reoccurrance?

  Remote

  Improbable

  Probable

• What corrective action already taken? If so, what?

• What (if any) corrective action is still needed?

• Select date

  Date

• Supervisor Signature

  Sign