CALIFORNIA LUTHERAN UNIVERSITY
Injured Person’s Supervisor Investigation Report
Name of Injured Person: Date of Injury:
Employee Student Guest
All statements and reports of a injury must be reported to Human Resources within 24 hours of incident. Detailed
descriptions and appropriate supporting documentation are crucial to proper claim submission with Travelers and
corrective action steps. If additional space is needed, please use the reverse side or additional pages as necessary.
Time of Injury: am/pm Injury Reported to:
Date reported to HR representative?
Did injury/incident occur on CLU property? Yes No
Location where incident occurred:
What was employee doing when injured?
Has employee received training if using specific equipment?
Describe fully the events and nature of injury/incident:
Body part injured:
What corrective actions steps are suggested (if any):
Witness(es):
UNSAFE CONDITIONS that caused or contributed to the incident (check all that apply)
Close clearance, congested workspace, protruding object Inadequate light
Hazardous atmosphere, inadequate ventilation Hazardous clothing, jewelry, hair, etc.
Hazardous arrangement, placement or storage Guards or safety devices missing or not functioning
Uneven or slippery walking surface Inadequate or missing warning system
Defective tools, equipment, etc. Unexpected movement hazards
Poor housekeeping Other (explain):
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UNSAFE ACTIONS that caused or contributed to the incident (check all that apply)
Unsafe body position or posture (improper lifting) Removing or modifying safety devices or guards
Lack of or improper personal protective equipment Operating at unsafe speeds
Failure to secure against unexpected movement Operating equipment without authority
Failure to warn or signal as required Service hazardous equipment or unauthorized
modifications
Horseplay, distracting, teasing, etc. Riding hazardous moving equipment
Improper tool inspection, maintenance or use Ignore safety rules, procedures, or policies
Using a defective tool or piece of equipment Other (explain):
PERSONAL or JOB FACTORS that caused or contributed to the incident (check all that apply)
Poor morale (short-cut, express hostility, attention, etc.) Lack of training or understanding (policies,
rules, procedures)
Physical/mental stress (fatigue, sub abuse, family issue, etc.) Lack of equipment, assistance or supervision
POLICY INFRACTION that caused or contributed to the incident (check all that apply)
Was there an infraction of a job rule, policy, practice, or procedure? Yes No
If yes, please describe the rule and infraction in detail:
If there was an infraction, were the proper policies/procedures reviewed with the worker? Yes No
Was the policy/procedure review documented (meeting notes, warning notice, etc.)? Yes No
Is there any reason to believe this is a non-work related injury/incident? Yes No
If yes, please explain:
I state the above is true and correct to the best of my knowledge.
Signature of Supervisor / Investigator Date
For HR Office Use:
Recvd: ____________________
Training documentation Employment documentation Witness Statement(s)
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