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.
