Supervisor's Accident Investigation Report

Activity at time of injury:

Was the activity in the course and scope of the employee's job duties?

Yes No

If no, explain:

Was the injury the result of a lack of training, poor physical layout, defective equipment, inadequate sinage, or other physical hazard?

Yes No

If yes, explain:

Who was notified of the safety concern?

Was the employee using personal protective equipment (PPE)?

Yes No

Was PPE required for this activity?

Yes No

Was PPE available to the employee?

Yes No

Would PPE have prevented or lessened the severity of the injury?

Yes No

Did the employee violate a safety rule, regulation, or procedure?

Yes No

If yes, explain:

Was this violation discussed with the employee?

Yes No N/A

What other actions, events, or conditions directly contributed to the injury?

What corrective actions have been taken to prevent a simular injury from occurring? (Please include the date each action was taken)

What additional training, equipment, procedures, or other actions could prevent a similar injury form occurring?

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