State of Wisconsin
University of Wisconsin System
UW-System
UWS/OSLP-2 (2/98)
SUPERVISOR’S ACCIDENT ANALYSIS AND PREVENTION REPORT
SUPERVISOR’S REPORT
INSTRUCTIONS:
1.
Within 24 hours of notice of the accident
,
complete this report.
2.
Send report to the Worker’s Compensation Coordinator.
3.
If you were not present at the time of injury, interview the employee.
Employee Name
Social Security Number Job Classification
Department Name and Location Work Unit
Date of Accident Time of Accident
/ /
Date injury reported
/ /
ACCIDENT DESCRIPTIONS:
From your analysis, describe in detail the action, occurrence or event that resulted in the accident.
Identify the exact location where the accident took place: Repetitive activities, lifting or material handling, exposure to chemicals,
push/pull or slip and fall, etc. If equipment related, was it defective? Could it be modified to prevent further injuries? Were safety
procedures followed? Have employe’s job duties changed recently? If so please explain.
Safety devices or other equipment in use at time of accident:
What action could be taken to prevent a similar accident?
Do you agree with the employee's account of the accident?
Yes
No If NO, Please explain.
Has the employee ever reported any previous physical condition(s) associated with work or non-work activities (second job, sports,
etc. that could be related to or aggravated by this injury / illness?
Yes
No If YES, please explain
Supervisor's Name (Please Print) Date
Title Phone #
( )
*If injury involved repetitive motion or material handling, Supervisor must complete reverse side*
SUPERVISOR’S EVALUATION OF REPETITIVE MOTION AND/OR
MATERIALS HANDLING ACTIVITIES
Repetitive Motion:
What specific activities does the employee perform with his/her wrists, hands, arms, shoulders, and/or neck?
How many hours per day?____________________
How many hours per week?____________________
Material Handling Injury:
Description of object/person being handled/lifted at time of injury.
Approximate size:____________________
Approximate weight:____________________
With what frequency, pace and duration is the object/person handled/lifted? (eg, 10 times/hour for 3 hours)
What material handling equipment and/or safety devices were available to the employee? Were they used properly?
Has the employee received training in proper body mechanics/lifting techniques? If YES, please indicate approximate date and type of
training given.
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