Supervisor Incident Report

/Supervisor Incident Report
Supervisor Incident Report2018-04-16T09:14:33+00:00

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Municipality

Department Name

Claim#

Exact Location of Incident

Date & Time of Incident

Date Reported to Supervisor

Temperature

Weather Conditions

Light Conditions

Name of Employee:

Occupation / Job Title

Length of Time in Position

Description of Incident

Injury / Illness Type (check all that apply)

Abrasion Puncture / Laceration Crushing Amputation
Contusion / Bruise Sprain / Strain Cumulative Trauma Fracture / Dislocation
Burn, Thermal Burn, Chemical Electric Shock / Burn Heat / Cold Stress
Respiratory Distress Poisoning Plant /Insect / Animal Other

Contributing Acts or Conditions (check all that apply)

Lifting /material handling Fatigue /physical condition Posture / positioning Equipment maintenance Equipment selection Equipment material use Personal Protect. equip
Sudden movement Equipment maintenance Housekeeping Warnings / labeling Use of safety features Proper authorization Other

Root Causes & Contributing Factors (check all that apply)

Knowledge /training Selection / placement Supervision Engineering controls PPE use / condition Inspection maintenance Other
Equip. specifications Feedback system Policy / practice EE attitude / behavior Drug /alcohol /horseplay Environmental conditions Other
Was Personal Protective Equipment (PPE) or other safety controls in place and being used?
YesNo

List PPE / controls being used:

Name & Contact Information for Witness(es):

Employees Description of Incident(as related to Supervisor) Attach additional statements if needed.

Supervisor's Description of Incident(Clearly relate events leading to incident and attach additional pictures, diagrams, etc)

Why did this incident happen? (List all factors that helped to cause the incident)

What could be done to prevent the reoccurrence?

Date of most recent training relevant to this incident:

Supervisor Signature(type your name here)

Date

Property Damage

Describe Property Damaged in this incident. What actions(s) or lack of actions(s) contributed to this loss?

Safety Committee Review: What could be done to prevent reoccurrence?

What action(s) can be taken? Who is responsible for taking action? By When?



Please click Print Form button before hitting Submit. Your form will be converted to a pdf file. Depending on your settings, you may be prompted to Save or Download the PDF before printing.

Distribution

When you hit submit, this form will be transmitted to J.A. Montgomery Risk Control who will then forward to Qual-Lynx. You should also print a copy for your records and Safety Committee review. Please refer to the instructions on the JIF website, for mailbox, email or fax addresses.