Fillable WC Supervisor Accident Form

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WC Supervisor Accident Form

On average this form takes 15 minutes to complete

The WC Supervisor Accident Form form is 1 page long and contains:

  • 1 signature
  • 29 check-boxes
  • 42 other fields

Country of origin: US
File type: PDF

U.S.A. forms for City

BROWSE CITY (AR) FORMS

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Explain:
Corrective Actions
___ Poor ventilation
___ Unsafe arrangement or process
___ Unsafe equipment
___ Unsafe position
___Other__________________________
___ Failure to secure
___ Horseplay
___ Improper dress
___ Improper guarding
___ Improper instruction
___ Improper protective equipment
___ Inoperative safety device
___ Lack of training or skill
___ Operating without authority
Physical Limitation
Part of body affected/injured. (Specific Details):
PLEASE INDICATE ALL OF THE FOLLOWING WHICH CONTRIBUTED TO THE INJURY OR ILLNESS
___ Failure to lockout
___ Improper maintenance
___ Poor housekeeping
Root Cause
Incident Type: □BEHAVIOR □PROCESS □EQUIPMENT
List Property/Equipment Damaged:
Department:
Property/Equipment Damaged:
. □YES □
NO
Was the employee performing
normal job duty at the time of
injury?
□YES □NO
What was the employee doing when incident occurred?:
_________________________________________________________________
_________________________________________________________________
_____
How did incident occur?
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
____
Job Title:
Supervisor Accident Report
(To be completed by the employee's supervisor or other responsible administrative official)
Employee Injured:
Date & Time of Incident:
___ /___ /___ : □
A.M. □ P.M.
General Information
Location of Incident:
Witness:
Supervisor:
Supervisor #:
(____) -
Was the employee cautioned for failure to use personal protective equipment?
Was the employee coached on proper safety procedures regarding incident?
Was the employee trained on proper safety procedures regarding incident?
Date: ___ /___ /___
∞List training video(s):
Supervisor's corrective action to ensure this type of accident does not recur:
__________________________
Supervisor (Print)
______________________________
Date
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WC Supervisor Accident Form

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Completed 21 March 2020

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