Supervisor's Accident Report

• Job Name and Number

• Conducted on

  Date

• Prepared by

• Location
  Address

• Name of Injured Teammate:

• Date of Birth:

• Date and Time of Incident

  Date

• Type of Injury:

  Cut

  Bruise

  Fracture

  Sprain/Strain

  Other

• Body Part: (Arm, Hand, etc)

• Side of body?

  Left

  Right

  Middle

• What was the Teammate doing when injured?

  Select Trying Carrying Climbing Walking Prying Other

  • Trying
  • Carrying
  • Climbing
  • Walking
  • Prying
  • Other

• Describe:

• Travel Distance?

• Weight?

• Describe Terrain Conditions? (Muddy, level, un-level, etc.)

• Was teammate using PPE?

  Yes

  No

  N/A

• Type of equipment used (Hickey bar, Chokers, etc.)

• Was any hazardous material involved?

  Yes

  No

  N/A

• What was the material involved?

• How did the injury happen?

• Was the hazard covered during Pre-task review?

  Yes

  No

  N/A

• What specific unsafe act or condition was responsible for this accident?

• Why was this specific act or condition responsible for this accident?

• How long has employee been performing this task?

• How often is this tasked performed? (daily, monthly)

• How could this injury been prevented?

• Number of teammates involed?

• Was injury caused by another person

  Yes

  No

  N/A

• Name of person that caused the injury?

• Were there witnesses?

  Yes

  No

  N/A

• Has the witness completed the "witness accident report" form?

  Yes

  No

  N/A

• Is this injury an original injury or a reinjury of a preexisting condition?

  Original Injury

  Preexisting condition

Off-Site Treatment

• Did the teammate see a doctor?

  Yes

  No

  N/A

• Doctor:

• Facility:

• Address:

• Telephone:

Supervisor Signature

• Sign

  Sign