Report Only____
First Aid _______
OHP __________
ER _______
Submission of this form does not reflect admission of fault
PERSONAL INJURY/ILLNESS REPORTS
(Supervisors please complete and return to HR immediately)
NAME OF INJURED
DATE OF REPORT
LOCATION IN PLANT WHERE INJURY OCCURRED & Assigned Team
JOB TITLE
SHIFT
DAY & TIME OF ACCIDENT ___:___AM
Sun Mon
Tues
Wed
__ __:__PM
Thurs Fri Sat
DESCRIPTION OF ACCIDENT (indicate specific actions at time of the injury, what the employee was doing.)
ACCIDENT CAUSE (What actually caused the injury/was proper PPE worn?)
SIGNATURE OF EMPLOYEE:
DATE:
SIGNATURE OF SUPERVISOR:
DATE:
WITNESSES
1.
2.
NATURE OF INJURY (specific part of body injured and extent of injury, Use back as reference)
WAS EMPLOYEE WORKING OVERTIME?
DID THIS INJURY OCCUR DURING PM DAY?
YES
YES
NO
NO
# of consecutive days: ___________
OCCUPATIONAL ILLNESS (specify toxic substance, noise, radiation, etc.)
MEDICAL TREATMENT PROVIDED (describe care given and by whom)
FOLLOW UP INSTRUCTIONS GIVEN (by OHP, STAT CARE, SRHC-ER)
LOST TIME Yes
To be completed by HR
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No
Report Only____
First Aid _______
OHP __________
ER _______
Submission of this form does not reflect admission of fault
Date investigation returned: ____________________
PERSONAL INJURY/ILLNESS REPORT
To be completed within 3 Working Days of Accident by Supervisor and Safety Manager.
NAME OF EMPLOYEE:
DATE OF ACCIDENT:
BRIEF DESCRIPTION OF WHAT HAPPENED:
ACTION TAKEN TO PREVENT A REOCCURRANCE
Investigation Team:
Investigation Date:
SAFETY MANAGER COMMENTS:
WAS IT DONE
YES
IF NOT, DATE WHEN IT WILL BE DONE
DATE COMPLETED
NO
SIGNATURE OF SUPERVISOR
DATE:
SIGNATURE OF MANAGER
DATE:
SIGNATURE OF SAFETY MANAGER
DATE:
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Report Only____
First Aid _______
OHP __________
ER _______
Submission of this form does not reflect admission of fault
EMPLOYEE’S NAME:
Please indicate area of involvement with an X
Identified root cause:
Analysis tools used:
Hazard
Broken Glass
Flying objects
Lifting / Ergonomics
Moving Parts
Slips, Trips & Falls
Hot surface
Electric Shock
Falling Objects
Other
check
one
(Change the above to fit your
work)
Note – You will find you typically have repeat injuries or injuries common to your work. Change the Hazard
topics to fit your main injuries.
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Report Only____
First Aid _______
OHP __________
ER _______
Submission of this form does not reflect admission of fault
ADDITIONAL COMMENTS:
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