Supervisors Report Of Work Injury

Supervisor's Report of Work Injury- Page 1 Injured Employee: Job Title: Location: Date of Hire: Age of Employee: Date of Injury: Exact Location: Names of Witnesses: Date of Report: Employee Number: Department: Time in this Job (years): Time on this Shift (years): Injury To: Face or Head Eyes Body Arms Hands or Fingers Legs Toes or Foot Internal Lungs Type of Injury: Lacerations Strain/Sprain Hernia Fracture Puncture Abrasion Amputation Burns Foreign Body Skin Gas Treatment: First Aid Nurse Doctor's Care Seriousness: Serious Lost Time Fatality Remarks (Be Specific): Describe how employee was injured (What was employee doing? What duty or task?): What happened that resulted in this injury? (Examples: Slipped, tell, was struck) What factors equipment arrangements, instructions, rules, inherent hazards, skill, experience, materials, and other factors.) do How could such an accident be prevented or avoided? American LegalNet, Inc. www.FormsWorkFlow.com 2001 © American LegalNet, Inc. Supervisor's Report of Work Injury- Page 2 Investigating Committee (People to be included in accident investigations are listed below.) 1 . Injured Employee 2. Immediate Supervisor 3. Safety Committee Person 4. Shop Steward 5. Department Head (or Rep.) 6. Witnesses 7. Safety Dept. Representative 8. Designated Union Safety Rep. 9. Manager or Appointed Rep. NOTE: Report to be completed by immediate supervisor and turned into the Safety Department not later than the end of the day following the injury. All lost-time injuries or fatalities must be promptly reported. IMPORTANT: All fatalities or accidents resulting in five or more persons being hospitalized must be reported to the appropriate federal or state agency enforcing OSHA regulations within the applicable time limits. People to be included in accident investigations: Near Miss/No Injury: The extent of the investigation will be left to the discretion of the supervisor Lost Time or Fatality: Immediate Investigation 1. Injured Employee 2. Immediate Supervisor 3. Safety Committee Person 4. Shop Steward 5. Department Head (or Representative) 6. Witnesses 7. Safety Department Representative Final Investigation 1. Injured Employee 2. Immediate Supervisor 3. Safety Committee person 4. Shop Steward 5. Department Head (or Representative) 6. Witnesses 7. Safety Department Representative 8. Designated Union Safety Representative 9. Manager or Appointed Representative Slight (First Aid): Immediate Investigation 1. Injured Employee 2. Immediate Supervisor Nurse Consulted: Immediate Investigation 1. Injured Employee 2. Immediate Supervisor 3. Safety Committeeperson Immediate Investigation 1. Injured Employee 2. Immediate Supervisor 3. Safety Committee Person 4. Shop Steward 5. Department Head (or Representative) 6. Witnesses Final Investigation 1. Injured Employee 2. Immediate Supervisor 3. Safety Committee person 4. Shop Steward 5. Department Head (or Representative) 6. Witnesses 7. Safety Department Representative Doctor Consulted: American LegalNet, Inc. www.FormsWorkFlow.com 2001 © American LegalNet, Inc.