THIS IS YOUR RECORD -- KEEP IN YOUR FILE
SUPERVISOR'S REPORT OF AN ACCIDENT
Name of Injured Employee:___________________________________________________ Age
At plant
Length of Employment
On job
Department
Date of Report __________________________ Section
Head Eyes Trunk Arms
Hands Legs Toes Internal
Wounds Strain & Sprain Hernia Fracture
Amputation Burns Foreign Body Skin (occupational)
Death First Aid Only
Lost Time
Due to Delayed Medical Treatment Remarks:__________________________ __________________________________
Remarks:________________________ ________________________________ Date of Injury Hour
Remarks:______________________________________ ______________________________________________ Department Exact Location
Eyewitnesses ________________________________________________________________________________________________________ Describe accident: Include the machine, equipment, object or substance involved . . . . . All Details . . . . . Use back space if necessary
CAUSE: Mark basic cause X
UNSAFE CONDITIONS
Mark contributing cause, if any 1 2 3 4 5 6 7 8 9
O
UNSAFE ACTS
1 2 3 4 5 6 7 8 9
Inadequately Guarded Unguarded Defective Tools, Equipment, or Substance Unsafe Design or Construction Hazardous Arrangement Unsafe Illumination Unsafe Ventilation Unsafe Clothing Insufficient Instruction
Operating Without Authority Operating at Unsafe Speed Making Safety Devices Inoperative Using Unsafe Equipment or Equipment Unsafely Unsafe Loading, Placing, Mixing Taking Unsafe Position Working on Moving or Dangerous Equipment Distraction, Teasing, Horse Play Failure to use Personal Protective Devices
Why was the unsafe act committed? ____________________________
Why did the unsafe condition exist? ____________________________
Any physical disabilities? ________________________________________________________________________________________________ Number of previous disablng injuries _______________________________________________________________________________________ GUIDES TO CORRECTIVE ACTION Based on the cause checked above, I am taking the following corrective action:
UNSAFE ACT UNSAFE CONDITION
I f Supervisor Can't Handle, Then 5 Recommend To: (a) (b) (c) (d) 6 Follow Up Own Boss, OR Safety Committee, OR Maintenance Dept., OR ___________________
1 Stop the Behavior 2 Study the Job 3 Instruct (tell--show--try--check) 4 Follow Up 5 Enforce
1 Remove 2 Guard 3 Warn 4 Supervisory Training
What I am actually doing to prevent similar injuries____________________________________________________________________________ ______________________________________________________________________________________________________________________ What further recommendations? ___________________________________________________________________________________________ SIGNATURES
Immediate Supervisor or Foreman Received by Plant Manager or Superintendent
F417-048-000 supervisor's report of an accident 10-05
DEPARTMENT OF LABOR AND INDUSTRIES WISHA SERVICES DIVISION
1. Describe the accident in your own words just as you saw it happen. Describe the surroundings or setting before the accident and the position of the injured party in relation to the surroundings, then describe the steps in proper sequence leading to the accident that happened. If possible attach a picture or make a drawing.
2. Describe any near accidents you have observed in the past week.
3. Report any unsafe procedures you have observed in the past week. (Physical hazards are classed as unsafe procedures as well as human acts.)
F417-048-000 supervisor's report of an accident 10-05