Supervisor’s Report of Work Related Injury and Illness
Page 1 of 2
General Information:
Name of injured employee: Today’s date:
Date of incident/injury: Date reported: Time of incident/injury:
School Site/Department:
Location of injury/incident:
Employee # Sex: Male Female
Phone number where employee can be reached:
Job title:
Occupation at time of incident:
Months/years in occupation:
Home address:
Pre-placement medical evaluation? Yes
No N/A
Phase of employee’s workday at time of injury or incident
Break
Entering
or Leaving Facility Meal Performing Work Other________________
Severity of injury/illness/incident
Report Only – no treatment Physician Treatment Light Duty-Temporary Assignment
Lost Workdays-Days Away from Work Damage to Equi
pment, Facility, Etc. over $500
Other
Other workers involved or witness to incident (attach eye-witness statements):
Injury Information (check all that applies):
Accident
Type:
(what
caused
physical
harm or
discomfort)
Contact with
Electricity
Heat
Ch
emical
s
Co
ld
C
aught between
C
aught in
C
aught on
Cu
mulative
Ex
posure
Fall from height
Slip/Trip/Fall
Stress
Struck against
Struc
k by
St
udent caused
Ov
er exertion (strain)
Othe
r
Nature of
Injury:
Am
putati
on
B
ruise or contusio
n
Bu
rn
Cut or lacerati
on
Derm
atit
is
Foreign particle in
eye
Fracture
Hum
an bite
Illness
Insect bite
Mu
ltiple in
juries
Puncture
Repeated trauma
Scratch
Strain
or sprain
Othe
r
Part of
Body
Affected:
A
bdomen
Arm
s:
R
L
Ankle: R
L
Back
Ch
est
Elbow:
R
L
Eyes: R
L
Face
Feet: R
L
Finger: R
L
Han
d:
R
L
Head
Knee:
R
L
Legs:
R
L
Shoulder: R
L
Wrist: R
L
Othe
r
Description of how incident/injury occurred: What happened (if digital pictures are taken list picture reference numbers)?
(Attach additional pages as necessary.)
WKCCD, Taft College
Supervisor’s Report of Work Related Injury and Illness
Page 2 of 2
Contributing Factors
Workplace
conditions
that may have
contributed to
the accident
Defective tools or equipment
Excessive noise
Failure to warn or secure
Inadequate guard or protection
Inadequate lighting
Indoor air quality
Substandard housekeeping
Trip hazard
Vapor/Fume exposure
Other
Unsafe work
practices that
contributed to
the accident
Failure to use personal-protective
equip.
Horseplay
Improper body mechanics
Improper lifting
Improper loading or placement
Inattention
Making safety devices inoperable
Operating at improper speed
Operating equipment without authority
Rushing
Servicing equipment in motion
Was a code of safe practices violated? If so,
which one
Other
Incidence Sequence:
List tasks being
performed that led
to accident. Who
was involved in
these tasks?
Findings / Root Causes (Knowledge, ability, motivation, design, maintenance, environment)
List possible causes
or actions that may
have contributed to
the accident or
incident:
Corrective Actions Necessary:
What
corrective
actions
need to be
taken to
prevent
another
accident
(Indicate all
that apply)
Disciplinary actions
Improve warning & posting
Loading or placement training
Lockout and tagout of energy sources
Operating procedures posted
Operator training needed
Provide better warning
Replacement or supply safety
equipment
Safe lifting training
Specific equipment or task instruction
Use of necessary personal protective
equipment
Other
Do these corrective actions need to be made at
other sites also?
Corrective Actions Taken:
Clarify the specific
corrective actions
taken, who is
responsible and
when will they be
accomplished:
Supervisor’s Signature:
Date:
Administrator’s Signature:
Date:
click to sign
signature
click to edit
click to sign
signature
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SUPERVISOR’S REPORT OF INJURY
INSTRUCTIONS FOR USE
The form is comprehensive enough to serve as both the Supervisor’s Report and the template for
an accident investigation. Accident/Incident investigation is a required element for all employers
under the Injury and Illness Prevention Program (IIPP). Cal/OSHA notes an employer’s
investigation procedures, or lack thereof, when following up on complaints or audits. The form
has been specifically designed to be able to serve both purposes. It also provides supervisors
with a streamlined approach to incident analysis. It is only through thorough incident analysis
that effective prevention measures can be implemented.
The Supervisor’s Report of Injury form should be completed whenever an employee
reports a work-related incident. Whether the employee requires medical attention is not a
prerequisite to completing the form. Even if an employee does not need medical
attention, the form should still be completed. The form is designed to capture all relevant
elements of an incident, whether comprehensive or simple.
If the employee does not require medical treatment, the Supervisor’s Report is kept on
file by the designated person; usually Human Resources (do not send the form to SISC).
No further action is required. If an employee does not believe the incident caused an
injury that requires medical attention, do not force the employee to seek such treatment.
There is no reason to send an employee to see a physician if not necessary.
There is a common misconception that sending an employee to a physician is required to
avoid “liability.” There is no such liability being avoided by sending an employee to
seek medical treatment when not medically necessary. The Supervisor’s Report is the
official documentation and is legally sufficient.
If the incident caused an injury that requires medical attention, provide the employee with
the workers’ compensation claim form, DWC-1, and follow the claims procedures
outlined by SISC I.
In the event an employee reported an incident and originally did not believe medical
treatment was necessary, and later believes medical treatment is necessary, the claims
process is started at that point. There is no problem, or liability, if this occurs.
If you have any questions about completing the form, or would like assistance in implementing
the new form, please contact the SISC Risk Management Services department. Staff are
available for in-service, as well as hands-on incident investigation, with district staff.