anuary 2015
NORTH CAROLINA SUPERVISOR INCIDENT INVESTIGATION REPORT
Instructions: Begin investigation within 24 hours and attach the
Employee Incident Report
and
Witness Reports
to this report.
orward
all
reports within 72 hours
to the Program Administrator. If more room is needed, continue in a Word document and attach it to this submission.
Agency/University: Date of Incident:
Employee Name: Employee Phone #:
Incident Supervisor: Supervisor Phone #:
Incident Classifications (check all that apply)
Near Hit Injury Fatality Property Damage Spill Possible Blood Borne Pathogen exposure
Employee required:
First-Aid Only Medical treatment and released Hospitalized Other:
Employee:
Returned to work no restrictions Returned to work with restrictions Did not return to work (Lost Days)
Hazard Types (select one based on origination of injury in this preference order)
Violence or injuries caused by people or animals Transportation Fires or Explosions
Slips, Trips, Falls Surface Level Fall from Elevation Exposure to harmful substances or environment
Contact with objects or equipment (Struck By, Struck Against, Caught-on, Caught between, Puncture, Cut) Over-Exertion (lifting)
Bodily Motion (reaching, twisting, running) Other (List Here):
Names of Witnesses Interviewed:
Incident
Information
Describe the specific activity the employee was engaged in and the sequence of events. Include objects or substances that directly injured or made the employee
ill. Describe tools, equipment, and PPE in use. Describe property damage. Attach pictures or police reports. Describe the estimated damage to any vehicles or
equipment (make, model, ID number, etc.)
Is the activity part of the
employee’s normal job?
Yes
Prior to beginning activity, did the employee
review potential hazards/dangers?
Yes
Date employee last received
training for the activity.
/ /
No
No
What was the root cause of the incident? Ask why then ask why again (e.g. Why? The employee slipped on scrap metal. Why? The work area was not cleaned up.
Why? The employee was rushing to get a project done and did not take time to clean up the work area.)
Action taken or will be taken to prevent reoccurrence (If corrective action will occur in the future, provide estimated completion date.)
I hereby certify that the information I have provided is true and accurate. Any inaccurate or false statements may result in a delay in process of this claim. I further
understand that this information may be used to determine whether the claim will be paid or denied. I also acknowledge that I understand that in addition to being
disciplined for providing false and/or misleading information up to and including dismissal, I may also be subjected to additional criminal and/or civil liability.
Supervisor’s Name: Signature Date of Report: / /
Manager’s Name: Signature Date Reviewed: / /
The Supervisor will obtain the Managers’ signature and forward signed copies of the Employee Report, Witness Statements, and the Supervisor’s report to the
Program Administrator. The Program Administrator will send the Employee’s and Supervisor’s reports to the Manager’s supervisor, Local Safety Contact, Safety
Committee Chairperson, and Agency Safety Director within two business days. The WCA will receive all reports and all supporting documentation.
Program Administrator Name: Signature Date / /
Date Corrective Actions Completed:
