Injury/Incident Supervisor Investigation Report

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

If the employee has not already done so, they will need to complete the Employee Injury/Incident report even if they are not opening a workers comp. claim.

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

Date of Birth

mm/dd/yyyy

Email of Injured

Home Address

Injured Employee's Street Address, City, Zip

Phone Number

Phone

EMPLOYEE ID (G#) of Injured

if applicable

Campus

District Office

College of San Mateo

Cañada College

Skyline College

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

Was First Aid Given?

Yes

Was time lost?

Did employee miss all or part of their work shift?

Yes

IDENTIFICATION OF THE ACCIDENT FACTORS

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...

Specific activity the employee was performing when event/exposure occurred:

Any Witnesses?

Yes

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

Explain

Provide detailed explanation on the suggestion to prevent accident.

What corrective action has been taken?

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