Fillable Supervisors Injury Investigation Form A Bruise Temporary (City of Hickory)

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Supervisors Injury Investigation Form A Bruise Temporary (City of Hickory)

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The Supervisors Injury Investigation Form A Bruise Temporary (City of Hickory) form is 2 pages long and contains:

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File type: PDF

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Supervisor’s Injury Investigation Form
Name of Injured Person: _______________________________ Department_______________________
Address: _______________________________________________
______________________________________
City: ______________________ State: ______ Zip: _____________ Telephone Number: ____________________
Date of Injury: ____________ Time of Injury: _________________
(Choose One) Male Female Age: ___________ Job title at time of injury: ________________
Nature of injury: (check all that apply)
□ Abrasion, cut, laceration, puncture, scrapes
□
A
mputation
□
B
ack/Neck
□
B
roken bone
□ Bruise
□ Burn (heat)
□ Burn (chemical)
□
C
oncussion (to the head)
□ Crushing injury
□ Exposure (bodily fluids)
□ Eye (irritation, scratch, poke, gouge)
□ Sprain, strain
□ Damage to a body system (nerve, circulatory, etc.)
□ Other: __________________________
This employee works:
□ Regular Full Time
□
R
egular Part Time
□ Seasonal
□ Temporary
Supervisor’s Comments(if any):
Additional Comments on following sheet □
Why did the incident happen?
Unsafe workplace conditions: (Check all that
apply)
□ Inadequate guard
□ Unguarded hazard
□
S
afety device is defective
□
T
ool or equipment is defective
□
W
ork area/station is hazardous
□ Unsafe lighting
□
L
ack of needed personal protection
□ Lack of appropriate equipment/tools
□ No training or insufficient training
□ Slippery Conditions
□ Other: __________________________________
Unsafe acts by people: (Check all that apply)
□ Operating without permission
□
O
perating at unsafe speed
□
S
ervicing equipment that has power to it
□ Making a safety device inoperative
□
U
sing defective equipment
□ Using equipment in an unapproved way
□ Unsafe lifting
□
Ta
king an unsafe position or posture
□ Distraction, teasing, horseplay
□
F
ailure to wear personal protective equipment
□ Failure to use the available equipment/tools
□
O
ther: __________________________________
Is there a reason (such as “the job can be done more quickly”) that may have encouraged the unsafe conditions or acts?
_____ Yes
______ No If yes, describe:
Were the unsafe acts or conditions reported prior to the incident? □ Yes □ No
Have there been similar incidents or near misses prior to this one? □ Yes □ No
Comments:
Supervisor’s Signature: __________________________________________ Date: __________________
Department Head Signature: _____________________________________ Date: ___________________
Reset Form
City of Hickory Injury Report
Return to Risk/Human Resources with Industrial Commission Form 19
***SUBMIT THIS REPORT WITHIN 24 HOURS FROM TIME OF ACCIDENT/INCIDENT/INJURY***
Date of Accident: __________ Time of Accident: ___________ Date of Hire: ____________ Date of Birth: ____________
Last Name______________________ First Name: ___________________________ Middle Initial: ________
Department: ______________________ Position: ____________________________
Immediate Supervisor: _______________________________ Supervisor Notified: _______________________________
Date and Time Supervisor Notified: _____________________ Witnesses: ______________________________________
Address of Accident: _________________________________________________________________________________
If inside Building, Location within Building: _______________________________________________________________
List Names of any other Co-Workers Injured
(Each person must complete a separate report):
Last Name: __________________________________ First Name: ______________________________ MI: _______
Last Name: __________________________________ First Name______________________________ MI: _______
Did you visit?
□ City Nurse □ Doctor
□ ER/Urgent Care □ None
□ Yes □ No
Were you exposed to blood other than your
own?
□ Yes □ No
Personal Protective Equipment or Safety Equipment Being Used at the time of Injury:
□ Safety Glasses □ Respirator □ Mask □ Hearing Protection □ Safety Boots/Shoes □ Safety Vest □ Gas Detector □ Seat Belt
□ Hard Hat □ Gloves □ Flagging/Signage/Barricades in Place □ Chaps
□ Other (Specify) ____________________________________________________________________
Describe Fully How Injury Occurred and What Employee Was Doing When Injured:
List Specific Body Part(s) Involved
(Example: Right Hand, Left
Leg):
Injury Other Than City Co-Worker (citizen, etc):
Additional Comments (injured co-worker only):
Declaration: I certify that my statements made in this report are true, complete, and correct to the best of my knowledge and belief and
are made in good faith. I authorize investigation of all statements made in this report. I understand that false information may be grounds
for dismissal. If I was unable to complete this form, I certify I directed the person listed below to complete the form based on my answers.
Coworker Signature: _______________________________________ Date: ______________________________
If coworker did not complete this form, explain why:
Who completed the form for the coworker?__________________________________________
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Supervisors Injury Investigation Form A Bruise Temporary (City of Hickory)

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Completed 23 January 2021

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