Free F417-048-000 Supervisor's Report of an Accident - Washington

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