Fillable Supervisors Accident Investigation Form AI_FOR_FILLABLE_1

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Supervisors Accident Investigation Form AI_FOR_FILLABLE_1

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SIPE ACCIDENT INVESTIGATION REPORT
The injured employee’s supervisor shall complete the Accident Investigation Report immediately following an illness or injury
Provide as much detail as possible. PLEASE PRINT OR TYPE
GENERAL DATA DATE OF REPORT PAGE 1 OF 2
SCHOOL DISTRICT SCHOOL SITE SITE PHONE
EMPLOYEE NAME (PRINT)
DATE OF BIRTH (MM/DD/YY) GENDER
OCCUPATION (REGULAR JOB TITLE) DATE EMPLOYER WAS DATE THE EMPLOYEE
NOTIFIED OF INCIDENT WAS PROVIDED WITH DWC-1 FORM
EMPLOYEE USUALLY WORKS EMPLOYMENT STATUS (CHECK APPLICABLE STATUS AT TIME OF INJURY)
HRS/DAY DAY/WEEK TOTAL HRS/WEEK
FULL TIME PART TIME TEMPORARY SEASONAL
DATE OF INCIDENT TIME OF INCIDENT TIME EMPLOYEE BEGAN WORK IF EMPLOYEE DIED, DATE OF DEATH
: :
AM
PM
: :
AM
PM
UNABLE TO WORK AT LEAST
ONE FULL DAY AFTER DATE OF INJURY?
YES NO
LAST DAY WORKED DATE RETURNED TO WORK IF STILL OFF WORK, EXPECTED RETURN DATE
IF THE PHYSICIAN IS NOT FROM THE RECOMMENDED MEDICAL CLINICS FOR WORKERS’ COMPENSATION INJURIES, DOES THE EMPLOYEE HAVE A FORM ON FILE
TO SEE A PERSONAL PHYSICIAN?
YES NO
WHO TRANSPORTED THE EMPLOYEE TO THE DOCTOR?
MALE FEMALE
INJURY/ILLNESS DATA PLEASE CHECK ALL THAT APPLY
CLASS OF INJURY
FATALITY LOST WORKDAY RESTRICTED WORK MEDICAL ONLY FIRST AID FOR RECORD ONLY
NATURE OF INJURY
DID THE INJURY OCCUR ON SCHOOL DISTRICT PROPERTY?
YES NO IF NO, LOCATION OF INCIDENT
WAS THE INCIDENT SCENE VISITED AS PART
OF THIS INVESTIGATION? IF YES, BY WHOM?
YES NO
WERE PHOTOS TAKEN AT THE SITE OF THE INCIDENT?
YES NO
IF YES, INCLUDE WITH REPORT
NAME OF SUPERVISOR
ABRASIONS
AMPUTATION
BITES/STINGS
BURNS
CONCUSSION
CONTUSION
PART OF BODY AFFECTED
ABDOMEN
ANKLE
ARM
BACK
CHEST
ELBOW
EYES
FINGER
FOOT
HAND
HEAD/FACE
HIP
KNEE
LEG
NECK
SHOULDER
TEETH
TOE
WRIST
OTHER
TYPE OF ACCIDENT
ASSAULT OR VIOLENCE
BODILY REACTION
FALL FROM ELEVATION
FALL TO FOOT LEVEL
FIRE OR EXPLOSION
MOTOR VEHICLE
OVEREXERTION
SLIP
TRIP
OTHER
CRUSHING
DISLOCATION
FOREIGN BODY
FRACTURE
HEARING LOSS
HERNIA
INFECTIOUS DISEASE
LACERATION
MENTAL DISORDER
POISONING
PUNCTURE
RASH
REPETITIVE MOTION
RESPIRATORY
STRAIN/SPRAIN
OTHER
HEAT EXHAUSTION/
STROKE
CAUGHT IN, UNDER OR BETWEEN
EXPOSURE
STRUCK AGAINST
STRUCK BY
SOURCE OF INJURY
AIR PRESSURE
ANIMAL
CHEMICAL
ELECTRICAL
ENVIRONMENTAL
EXTREME TEMPERATURE
HAND TOOL
HUMAN
INFECTIOUS AGENT
INSECT
LADDER/SCAFFOLD
LIFTING/CARRYING
MACHINERY
NEEDLESTICK
NOISE
PARTICULATES
PARTS & MATERIALS
POWER TOOL
PUSHING OR PULLING
STAIRS
VEGETATION
VEHICLE
WORKING SURFACE
OTHER
DEFECTIVE TOOLS/EQUIPMENT
ENVIRONMENTAL HAZARD
EXCESSIVE NOISE
HAZARDOUS WORKSURFACE
IMPROPER DESIGN
IMPROPER USE OF TOOLS
IMPROPER WORKSPACE
INADEQUATE GUARDING
INADEQUATE ILLUMINATION
INADEQUATE VENTILATION
LACK OF MAINTENANCE
LACK OF WARNING SIGNS
POOR DESIGN
POOR HOUSEKEEPING
UNPREDICTABLE ACTIONS
UNSUITABLE MATERIAL
OTHER
UNSAFE CONDITIONS
UNSAFE ACT
CREATING ADDITIONAL
HAZARDS
FAILURE TO FOLLOW
INSTRUCTIONS OR PROCEDURES
FAILURE
FAILURE TO IDENTIFY A HAZARD
FAILURE TO INSPECT
EQUIPMENT
FAILURE TO USE PPE
WEARING IMPROPER ATTIRE
HORSEPLAY
IGNORED KNOWN HAZARD
IMPROPER LIFT/CARRY
INATTENTION TO FOOTING
OR SURROUNDINGS
JUMP FROM ELEVATION
MISUSE OF TOOLS/EQUIPMENT
UNAUTHORIZED OPERATION
REMOVING SAFETY DEVICES
UNSAFE BODILY POSITION
UNSAFE SPEED
USING UNSAFE EQUIPMENT
NO UNSAFE ACT
OTHER
Print Form
Please Select District
DESCRIPTION OF ACCIDENT
TO BE COMPLETED WITH INJURED EMPLOYEE (ATTACH A SEPARATE SHEET IF NECESSARY)
CORRECTIVE ACTION
REQUIRED SIGNATURES
INVESTIGATED BY:
DATE:
REVIEWED BY DIRECTOR/SITE ADMINISTRATOR:
DATE:
REVIEWED BY DISTRICT SAFETY COORDINATOR DATE:
PAGE 2 OF 2
SUPERVISORY RESPONSIBILITY
FAILURE TO ENFORCE SAFETY RULES
FAILURE TO PROVIDE PROPER PPE
FAILURE TO PROVIDE PROPER TOOLS
FAILURE TO PROVIDE PROPER TOOLS
IMPROPER MAINTENANCE
INADEQUATE INSPECTIONS
LACK OF PROCEDURES
POOR COMMUNICATION
WRONG PERSONNEL ASSIGNED
NOT APPLICABLE
OTHER
LACK OF EQUIPMENT
LACK OF OVERSIGHT/SUPERVISION
LACK OF PLANNING
Describe in detail what happened:
Provide exact location where accident occurred and be specific.:
Describe how the injury occurred:
Describe the activity, sequence of events, and conditions that led to this accident:
Could the accident have been prevented?
YES
NO
Please explain.
Names and statements from witnesses:
(ATTACH STATEMENT ON A SEPARATE SHEET)
Name:
Signature:
Who is responsible for corrective action and what is the expected completion date?
What corrective action will be taken to prevent recurrence?
PRINT THE NAME OF THE PERSON FILLING OUT THIS REPORT:
Name:
Signature:
Name: Date:Name: Date:
DATE:
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Supervisors Accident Investigation Form AI_FOR_FILLABLE_1

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Completed 15 November 2019

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