Supervisor's Accident Investigation Report

* Indicates a required field

Injured Employeee Information


Was the activity in the course and scope of the employee's job duties?
Was the injury the result of a lack of training, poor physical layout, defective equipment, inadequate sinage, or other physical hazard?
Was the employee using personal protective equipment (PPE)?
Was PPE required for this activity?
Was PPE available to the employee?
Would PPE have prevented or lessened the severity of the injury?
Did the employee violate a safety rule, regulation, or procedure?
Was this violation discussed with the employee?