Supervisor's Injury Investigation Report

• Branch Location

  Select

• Affected Employee's Name

• Date of Hire

  Date

• Employee Position

• Date of injury

  Date

• Date of Report

  Date

• Person completing the investigation:

SITUATION

• Description of Injury (SBI Model)

• Body Part Injured

• Time of Injury

  Date

• Time Employee Started

  Date

• Location where incident happened

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

  Yes

  No

  N/A

• Name of Witness

• Was a drug screen performed?

  Yes

  No

  N/A

• Why not?

Root Cause Analysis

• Contributing (underlying) Factors or Behaviors:

Training for Affected Employee

• Training for affected employee?

• What is the target completion date?

  Date

• Who will complete the training and how?

Training for the Workgroup

• What training will the workgroup get?

• What is the target completion date?

  Date

• Who will complete the training and how?