Injured Employee Investigation Report
Page 1 of 2
Important: The supervisor should complete this form immediately after the incident.
Organization Name:
Branch/Location:
Injured Employee Name:
Male
Home address:
Female
Phone:
Date of hire:
/
/
Job title:
Officer:
Yes
No
International Staff:
Yes
No
Full-Time:
Yes
No
Part-Time:
Yes
No
Date of injury:
/
/
Was first aid provided onsite?
Seasonal Staff:
Time of injury:
Yes
No
AM
Yes
No
PM
Was outside medical attention sought?
Yes
No
(If applicable) Name of facility or physician that provided treatment:
Supervisor signature:
Date:
/
/
What were you doing just before the incident occurred? Describe the activity and any materials, equipment, or tools
being used – be specific. For example: “climbing a ladder while carrying roofing materials” or “entering data into computer”
What happened? Tell how the incident occurred, including where you were. For example: “the ladder to the roof was not
secured; it slipped, and I fell” or “I was on the ball field helping a child get up; while lifting the child something in my back snapped”
What was the injury or illness? Explain what body part was affected and how it was affected – be specific. For example:
“sprained lower back” or “chemical burn in eyes” or “multiple contusions and abrasions on arms, legs, and shoulder”
Were there witnesses to the incident?
Yes
No If “Yes”, provide names and phone numbers below
Name:
Phone:
Name:
Phone:
Name:
Phone:
DIRECT SUPERVISOR’S ACCIDENT INVESTIGATION Please categorize the incident on page 2 of this report
Accident / exposure description – Identify the immediate cause, any intermediary causes, and root cause of the incident
Preventive action recommendations – If root cause is protocol, defective equipment, or training, suggest correction
Corrective actions taken – If root cause is violation of safety rule, explain corrective action taken
Supervisor:
Signature:
Director Responsible:
Reviewed
Date:
Executive Director:
/
/
Reviewed
Please complete page 2 of this form (over)
THE REDWOODS GROUP
IEIR 2/10/16
Injured Employee Investigation Report (cont.)
Page 2 of 2
Please check one and only one box in each of the following sections:
SPECIFIC LOCATION OF INCIDENT
Aquatics Area
Athletic / Play Field
Before/After School
Cabin / Tent
Campfire / Meeting Area
Challenge Ropes Course
Child Watch / Babysitting
Childcare Area
Class / Meeting Room
Climbing Wall / Tower
Ex Room: Aerobics, Zumba Etc.
Ex Room: Cardio / Strength
Equip
Ex Room: Free Weights
Gym
Gymnastics Area
Kitchen/Food Prep
Lobby / Halls / Front Desk
Locker / Rest Room /Showers
Maintenance / Service Area
Parking Lot / Garage
Play Structure Or Area (Int.)
Playground (Ext.)
Pool
Racquetball / Tennis
(Etc.) Court
Residence Facility
Off Premises / Inside
Off Premises / Outside
On Premise / Outside
Roadway / Streets
Sidewalks / Pathways
(On Premise)
Sidewalks / Pathways
(Off Premise)
Skating Rink / Skate Park
Spa / Sauna / Steam
Stables / Horses
Stairs / Exterior
Stairs / Interior
Waterfront (Non-Pool)
Other
Health & Fitness: Personal
Maintenance / Housekeeping
Office Staff
Senior Program / Activity
Social Outreach (Incl. Residence)
Special Events / Field Trips
Sports: Adult
Sports: Youth
Other
PROGRAM NAME
Aquatics
Camp: Day / Holiday
Camp: Resident
Camp: Sports
Childcare: Before & After
Childcare: Child Watch
Childcare: Preschool / Daycare
Custodial / Housekeeping
Food Prep
Health & Fitness: Organized
GENERAL ACTIVITY
Aquatics: Boating, All Forms
Aquatics: All Others
Aquatics: Lifeguard
Aquatics: Operating
Animal: Care
Baseball / Softball / T-Ball
Basketball
Bicycles / Motorbikes/Golf Carts
Class: Aerobics
Class: Kick-Boxing
Class: Martial Arts
Climbing
Dance
Exercise: Cardio Equip.
Exercise: Free Weights
Exercise: Strength Equip.
Exercise: Run / Walk
Exercise: Other Personal
Football
Games / Structured Activity
Gymnastics Demo
Gymnastics Spot
Hiking / Backpacking
Hockey (Ice or Roller)
Horseback Riding
Housekeeping
Landscaping
Lifting / Moving: Child
Lifting / Moving: Objects
Maintenance
No Accident Reported
Office Work
Playground Equipment
Racquetball / Tennis / Squash
Skateboarding
Skating (Ice or Roller)
Skiing / Snowboarding
Skiing / Water
Soccer
Transportation / Driving
Volleyball / Walleyball
Walking (Incidental)
Other
SPECIFIC ACTION
Aggressive Behavior Of / By
Bending / Kneeling
Caught In, By, or Between
Climbing
Contact With / Exposure To
Cutting
Driving / Riding
Exertion
Fall (From, Onto, Into, or Against)
Horseplay
Inhale / Ingest
Lifting / Moving
No Accident Reported
Participation / Playing
Pushed / Pulled / Bumped
Slip
Door
Environment: Sun, Heat, Etc.
Equipment: Exercise
Equipment: Housekeeping
Equipment: Office
Equipment: Playground
Equipment: Tools
Floor / Ground
Furniture
Insect / Animal / Poison Ivy
Ladder / Step Stool
Machinery
Object (Ball/Bat/Toy/Nail Etc.)
Swimming
Struck By / Against
Trip
Typing / Keying
Other
SOURCE OF INJURY
Aquatics Facility: Deck / Dock
Aquatics Facility: Equipment
Aquatics Facility: Sides / Bottom
Aquatics Facility: Body of Water
Aquatics Recreation Equipment
Blood / Body Fluids
Chemicals
Person (Another)
Self
Vehicle
Wall / Vertical Surface
Other
APPARENT INJURY
Abrasion / Scratch
Bite / Sting
Breathing Shortened / Impaired
Bruise / Contusion
Burn / Blister
Chemical Exposure
Dislocation
Dizziness / Unconscious
Fracture / Break
Irritation / Reaction / Rash
BODY PART  please check if applicable
Arm
Hand
Wrist
Elbow
Finger
Leg
Foot
Ankle
Knee
Toe
Shoulder
Chest
Stomach
Side
Back
Buttocks
right
Jam
Laceration / Cut
Pain / Soreness
Pinch / Crush
Puncture
left
Hip
Groin
Face
Ear
upper
Eye
Nose
Head
Neck
Seizure / Dysfunction
Sprain / Strain
Stress / Mind / Psyche
No Visible / Apparent Injury
Other
lower
Heart
Lungs
Mouth / Lips
Mind / Psyche
Teeth
None / Not Applicable
Other
FOOTWEAR – for Slip, Trip, Fall injuries:
Barefoot
Boot / All Weather Shoe
THE REDWOODS GROUP
Closed Toe Flat Shoe (Sneaker or Athletic)
Closed Toe Flat Shoe (Other than Sneaker
or Athletic)
Flip Flop / Sandal
Heels
Protective Shoe (Steel
Toed Shoe / Boot, etc.)
Other
IEIR 2/10/16