PDF VERSION OF FORM MUST BE OPENED WITH INTERNET EXPLORER:
opens in a new windowBURLCO JIF Supervisor Incident Report (SIR) (pdf file must be opened using Internet Explorer as your Browser and downloaded/viewed in Adobe Reader)
Instructions – Supervisor’s Incident Report Instructions
Instructions for Supervisors:
- The Supervisor’s Incident Report DOES NOT REPLACE the NJ First Report of Injury.
- The purpose of the Supervisor’s Incident Report is to identify root causes and prevent future occurrences: FACT FINDING, NOT FAULT FINDING.
- The Supervisor Incident Report may be used to investigate Workers’ Compensation, Property, Automobile, and General Liability Incidents.
- Claims Coordinators should continue to report claims as previously instructed.
- Action Items should be forwarded to a responsible individual to act on the managerial or financial aspects of the stated action item.
When an Accident Occurs:
- Render any necessary medical assistance.
- Take steps to secure the site.
- Notify law enforcement if motor vehicle is involved.
- Take photos and preserve equipment involved in the accident.
- Use the Incident report form as a guide to identify ways to prevent future occurrences.
- Prepare the report in sufficient detail that the basic facts can be documented and so that corrective action(s) can be identified, and accountability assigned.
- Participate in the Safety Committee or Accident Review discussion of the incident.
- Follow-up and provide feedback on the implementation of action items assigned to you.
Suggested Report Distribution:
Supervisor – Send completed report to Claims Coordinator; Attach Police Report, and photos for all Motor Vehicle and property damage reports.
Claims Coordinator – Send completed Supervisor Incident Investigation Report to:
- J.A. Montgomery Risk Control
- Your Municipal Safety Coordinator