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Form #666

Supervisor's Report of Work Injury

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Supervisor's Report of Work Injury - Free Legal Form

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SUPERVISOR'S REPORT OF WORK INJURY

 

 

Date of Report _________________

 

Injured Employee ________________________________                  Age ______

 

Job Title ______________________                    Employee Number ___________

 

Location ______________________                    Department ________________

 

Date of Hire ___________________                     Time in this job (months) ______

 

Time on this shift (months) ____________

 

Date of Injury _____________________                               Time of Injury ______

 

Exact Location _____________________________________________________

 

Names of Witnesses _______________________

 

Injury to:

 

[  ] Face or Head         [  ] Legs         [  ] Eyes             [  ] Toes or Foot            [  ] Body

[  ] Internal                   [  ] Arms        [  ] Lungs           [  ] Hands or Fingers       

[  ] Other _______

 

Type of Injury:

 

[  ] Lacerations        [  ] Amputation       [  ] Strain or Sprain    [  ] Burns        [  ] Hernia

[  ] Foreign Body     [  ] Fracture            [  ] Skin                     [  ] Puncture   [  ] Gas

[  ] Abrasion            [  ] Other _______

 

Treatment:

 

[  ] First Aid           [  ] Nurse          [  ] Doctor's Care         [  ] Serious       [  ] Lost time [  ] Fatality

 

Remarks: Be specific (L or R arm, etc.) _____________________________________ ___________________________________________________________________ ___________________________________________________________________

 

Describe how employee was injured: (What was employee doing?  What duty or task?) ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________

 

What happened that resulted in this injury? (Examples: slipped, fell, was struck) ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________

 

1What factors do you believe contributed to this accident?  (Consider methods, procedures, tools, machines, equipment arrangements, instructions, rules, inherent hazards, skill, experience, materials, and other factors.) _________________________ ___________________________________________________________________ ___________________________________________________________________

 

How could such an accident have been prevented or avoided?  ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________

 

The investigating Committee (People to be included in the accident investigation 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 in to the Safety Department no 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 time limits applicable.

 

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.

 

Slight (First Aid)

 

Immediate Investigation

1. Injured Employee

2. Immediate Supervisor

 

Nurse Case

 

Immediate Investigation

1. Injured Employee

2. Immediate Supervisor

3. Safety Committee person

 

Doctor Case

 

Immediate Investigation

1. Injured Employee

2. Immediate Supervisor

3. Safety Committee person

4. Shop Steward

5. Department Head (or Rep.)

6. Witnesses

 

Final Investigation

 

1. Injured Employee

2. Immediate Supervisor

13. Safety Committee person

4. Shop Steward

5. Department Head (or Rep.)

6. Witnesses

7. Safety Dept. Representative Lost Time or Fatality

 

Immediate Investigation

 

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.

 

Final Investigation

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.

 

 

Contributed by
Vacuum Technologies LLC
 
Name of Firm Vacuum Technologies LLC
Total Forms Contributed 53
 

See All Vacuum Technologies LLC's Forms
 

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Terms Of Use

Submissions to this site, including any legal or business forms, posts, responses to questions or other communications by contributors are not intended as and should not be construed as legal advice. You are strongly encouraged to consult competent legal council before engaging in any action based upon content contained on this site.

These downloadable forms are only for personal use. Retransmission, redistribution, or any other commercial use is prohibited. This includes reposting forms from this site to another site offering free legal or other document forms for download.

Please note that the donator may have included different usage terms regarding this form, and you agree to abide by these terms. It is highly recommended that you have a licensed attorney review any legal documents for which you are searching in order to make sure that your needs are being properly and completely satisfied.

Your use of this site constitutes your acceptance of our terms of use and your agreement to hold this site, its officers, employees and any contributors to this site harmless for any damage you might incur from your use of any submissions contained on this site. If you do not agree to the above terms, please do not proceed.

These forms are provided to assist business owners and others in understanding important points to consider in different transactions. They are offered with the understanding that no legal advice, accounting, or other professional service is being offered by these documents or on this website. Laws vary in the different states. Agreements acceptable in one state may not be enforced the same way under the laws of another state. Also, agreements should relate specifically to the particular facts of each situation. Therefore, it is important to consult legal counsel whenever utilizing these forms. The Forms are not a substitute for legal advice YourFreeLegalForms.com is not engaged in recommending or referring members on the site or making claims about the competence, character or qualifications of its participating members.
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