Supervisor’s Accident Investigation Report
Division:___________________	Nature of Accident (please mark with check)	
Location:___________________	Employee Injury	____	First-Aid Only		____
					Vehicle Accident	____	Third-Party Injury	____
					Property Damage	____	Near Miss		____

1.	Name of Employee:______________________________________	Age:______________
2.	Occupation:____________________________________________	Dept.:_____________
3.	Date of Accident:________________________________________	Time:_____________
4.	Place of Accident:______________________________________________________________
5.	Witnesses:____________________________________________________________________
6.	Employee Treated by Physician?   Y    N	Name and Address of Physician:____________
	_____________________________________________________________________________
7.	Did Injured Leave Work?     Y    N		Returned to Work Next Business Day?   Y   N
8.	Describe Injuries/Damage:________________________________________________________
	_____________________________________________________________________________
	_____________________________________________________________________________
	_____________________________________________________________________________
9.	Describe Accident:______________________________________________________________
	_____________________________________________________________________________
	_____________________________________________________________________________
	_____________________________________________________________________________
10.	Accident Causes:(check all that apply)
	Physical Causes:					Personal Causes:
	___Defective/Improper tools or equipment		___Not properly trained/instructed
	___Poor housekeeping(trash, slippery floor, etc.)	___Failure to use Personal Protective             Equipment
	___Unguarded/Improperly guarded equipment		___Failure to follow rules or instructions
	___Congested area					___Using improper/defective tools
	___Unstable/Improper piling or storage			___Horseplay
	___Improper light					___Improper apparel
	___Poor ventilation					___Using improper methods/procedures
	___Extreme temperature				___Operating without authority 
	___Description of cause:_________________		___Distracted/Breakdown in awareness
	      __________________________________		___Description of cause:____________
	      __________________________________		      _____________________________
								      _____________________________
11.	Was accident:   Preventable/ Non-Preventable
12.	Disciplinary action taken?     Y    N
	If so, what type?	___Coaching
				___Verbal warning
				___Written warning
				___Suspension
				___Termination
13.	What should be done, and by whom, to prevent recurrence, and what is the expected completion date:_________________________________________________________________________
	_____________________________________________________________________________
	_____________________________________________________________________________

Signatures:	Prepared by:	_________________________________________________________
				(Supervisor)					(Date)
		Reviewed by:	_________________________________________________________
				(Safety Compliance Manager)			(Date)		
				_________________________________________________________
				(Department Head)				(Date)