Injury/Incident Supervisor Investigation Report

Injury/Incident Supervisor Investigation Report

Supervisor, please complete the following information to report the injury/incident.

Upon submission you will received an automated email from smartsheet with an attachment.

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Supervisor Name*

Supervisor Job Title

Supervisor Email*

Supervisor Phone Number*

Phone

Injured Person's Information

complete the following as it pertains to the injured

Name of Injured*

Gender

Select or enter value

Date of Birth

Email of Injured

Home Address

Street Address, City, Zip

Phone Number

Phone

EMPLOYEE ID (G#) of Injured

if applicable

EMPLOYMENT CATEGORY

Permanent Full-Time Employee

Adjunct Faculty

Short-Term/Student Assistant

Visitor

Volunteer

Student

Campus

District Office

College of San Mateo

Cañada College

Skyline College

Job Title

Department

Date of Hire

Date of Injury/Incident

Time of Jury/Incident

include AM/PM

Describe injury & party of body affected

Incident Location (Address)

Was injured seen/sent to Doctor?

Yes

No

If Yes, where?

Was First Aid Given?

Yes

No

First Aid Given by Whom?

Was time lost?

Did employee miss all or part of their work shift?

Yes

No

If yes, how many days?

Has the Employee returned to work?

Yes

No

Employee's Regular Work Schedule

i.e. Monday-Friday 8:30am-4:30pm

IDENTIFICATION OF THE ACCIDENT FACTORS

Accident Type

Struck by

Struck against

Overextended

Fall

Repetitive Motion

Caught in/on/between

Inhalation

Ingestion

Absorption

Contact with Electrical Current

Exposure to Temperature Extremes

Rubbed or Abraded

Injury and/or Damage:

Brief description of Incident (what happened):

Department Where Event or Exposure Occurred.

e.g. shipping department, machine shop...

Equipment, materials, and chemicals

used by employee when event or exposure occurred. e.g. acetylene, welding torch, scaffold. etc...

Any Witnesses?

Yes

No

Name(s) of Witness:

ACCIDENT CAUSES

What specific act caused the accident?

What specific condition caused accident?

Reasons that resulted in accident:

Lack of knowledge/experience

Attitude

Human Limitation

Condition

CORRECTIVE ACTION

Suggestions to prevent similar accident:

Instruction/Training

Motivation/Discipline

Proper Equipment Placement

Repair/Eliminate

Recommend to Manager

Explain

Provide detailed explanation on the suggestion to prevent accident.

What corrective action has been taken?

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