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 Am/Pm

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)

What 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.

PEOPLE TO BE INCLUDED IN ACCIDENT INVESTIGATIONS:

Near Miss/No Injury

The extent of the investigation will be left to the capable 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

3. 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.