Supervisor Accident/Incident Report

• Date/Time Of Accident

  Date

• Conducted By

• Project

• Location
  Address

• Weather Conditions

Employee Injured

• Employee Job Description

  Select

• Witnesses

Accident/Incident

• Was This A Vehicle Accident

  Yes

  No

  N/A

• Was Law Enforcement Called

  Yes

  No

  N/A

• Was This Caused By A Third Party

  Yes

  No

  N/A

• Describe

  Yes

  No

  N/A

• How Could This Incident/Accident Have Been Prevented

  Select

• In Your Own Words What Could Of Prevented This Accident

• Accident/Incident Description

Employees Injuries

• Did The Employee Suffer From Any Of The Following Illness/Injury

  Select

• Description Of Poison Ingested

• Description Of Insect/animal

• Description Of Animal

• Body Part The Emplyee Was Injured

  Select

• Describe Injury

  Select

• Describe The Injury

• Describe The Injury

• Was The SDS Available For Th Employee

  Yes

  No

  N/A

• Were The Instructions For Care Provided By The SDS Followed By The Employee

  Yes

  No

  N/A

• Describe The Injury

• Describe The Injury

• Describe The Injury

• Describe The Injury

• Describe The Injury

• Describe The Injury

• Describe The Injury

• Describe The Injury

• Was The SDS Available For The Employee

  Yes

  No

  N/A

• Were The Instructions For Care Provided By The SDS Followed by the employee

  Yes

  No

  N/A

• Describe The Injury

• Describe The Injury

• Describe The Injury

• Describe The Injury

• Describe The Injury

• Describe The Injury

• Photos Of Employees Injuries

  Media

Medical

• First Aid Only

• CPR Performed

• AED Used

• Was Treatment Required/Rquested

  Select

• Was The Employees Emergancy Contact Notified Of The Accident

  Yes

  No

  N/A

• How Was The Employee Transporter

  Select

• Was The Employees Emergancy Contact Notified Of The Accident

  Yes

  No

  N/A

• How Was The Employee Transporter

  Select

• Was The Employees Emergancy Contact Notified Of The Accident

  Yes

  No

  N/A

• How Was The Employee Transporter

  Select

Equipment/Tools Involved

• Equipment/Tools Used During Accident/Incident

• Photos Of Equipment/Tools If Damaged

  Media

• PPE Available For The Tasks Being Performed

  Select

• PPE Worn For The Tasks Being Performed

  Select

• Was Work Plan In Place And Followed

  Yes

  No

  N/A

• Was The Work Plan Being Followed

  Yes

  No

  N/A

• Descripe How Work Plan Was Not Followed/In Place

• Was The Injured Employee Competent/Qualified To Perform The Task Assigned

  Yes

  No

  N/A

• Supervisor Signature

  Sign