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Form #666Supervisor'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 ________________________________Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Age ______
Job Title
______________________Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Employee Number ___________
Location
______________________Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Department ________________
Date of Hire
___________________Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Time in this job (months) ______
Time on this
shift (months) ____________
Date of Injury
_____________________Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Time of Injury ______
Exact Location
_____________________________________________________
Names of
Witnesses _______________________
Injury to:
[Â ] Face or
Head        [ ] Legs        [ ] Eyes            [ ] Toes or
Foot           [ ] Body
[Â ]
Internal                  [ ] Arms       [ ] Lungs          [ ] Hands or
Fingers      Â
[Â ] Other
_______
Type of
Injury:
[Â ]
Lacerations       [ ] Amputation      [ ] Strain or Sprain   [ ]
Burns       [ ] Hernia
[Â ] Foreign
Body    [ ] Fracture           [ ] Skin                    [ ] Puncture Â
[Â ] Gas
[Â ]
Abrasion           [ ] Other _______
Treatment:
[Â ] First
Aid          [ ] Nurse         [ ] Doctor's Care        [ ] Serious     Â
[Â ] Lost time [Â ] 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. WitnessesÂ
____________________________________________
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:Â
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.
Our Spam Policy
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regading how we deal with your email. We pledge that we will:
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Submissions to this site, including any legal or business forms, posts, responses
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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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Keywords: Supervisor, Report, Work Injury, legal forms
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