Supervisor’s Review of Employee Accident / Incident Report
Supervisor’s Review of
Employee Accident / Incident Report
Accident / Incident Date:
Type of Injury/Illness:
Describe Accident/Incident:
Time: Location:
Witness(es)
Evaluate and report on items in each of the "systems" below that may have contributed to this accident / incident. See "Instructions" for examples.
Management
Equipment
Employee
Environment
Phone:
Signature Date
COMPLETE FORM AND SUBMIT WITH EMPLOYEE REPORT TO HUMAN RESOURCES
** See reverse for instructions **
Rev. 11/2010
INSTRUCTIONS
This document is to be completed and signed by the direct supervisor of the effected employee. The purpose of an accident analysis is to determine facts (not to place blame) and to utilize those facts to make recommendations on prevention of future reoccurrences.
3.
4.
1.
2.
Enter injured worker's full name
Enter injured worker's job title
Enter the date and time of injury
Enter the physical location of the accident/incident
5.
6.
Describe the accident/incident
Enter witness(es) name and contact information
7. Enter contributing to the accident/incident (examples: lack of policy enforcement, hazard recognition, accountability, supervisor training, corrective action, production priority, proper resources, job task orientation, hiring practices, written job description, preventative maintenance, adequate staffing, etc.)
8. Enter Employee behavior contributing to the accident/incident (examples: not following procedure, poor training, pre-existing condition, mental or physical capacity, improper equipment use, short cuts, personal protective equipment not worn, poor attitude toward safety, etc.) the contributing to the accident/incident (examples: improper tools, inadequate tools, lack of available tools, inadequate processes, improper maintenance, fail to heed manufacturer warning, improper or no guarding, etc.) the contributing to the accident/incident (examples: plant layout, chemical, temperature, noise, radiation, weather, terrain, vibration, ergonomics, adequate lighting, adequate ventilation)
11. Determine and describe Recommendations for Preventing Reoccurrences of a similar accident/incident
