Supervisor Accident Investigation Report Guidelines
OVERVIEW
An employee injured on the job is required to report the injury to his/her supervisor as soon as possible after the incident/accident. The supervisor is responsible first, to assure that any injured employee is given immediate and proper medical care (as required) and that no one else can be injured and, second, to immediately (within 8 hours) contact the Environmental Safety & Health office (EH&S – X 2401) to report the accident. Environmental Safety & Health staff are available to assist the supervisor with the accident investigation.
The purpose of accident investigation is to develop information on the actual and contributing causes of accidents in order to prevent recurrence. No matter how conscientious the safety effort at the University, accidents are sometimes going to happen due to human or system error. Our goal is to find and remove accident causes and to make the University a safer place to work. Accident investigations help us meet that goal.
The following is a brief overview of the investigation and report form (Form 620) that is required for every employee accident. All blanks should be filled in.
GENERAL INFORMATION
This section identifies the injured employee, the department and employee status.
ACCIDENT DATA
This section describes the accident with specifics on what the injured employee was doing and which body parts (right hand, left lower leg, back of head) were affected. The specific time and place (building, room, area) of the accident is important in the investigation.
The type of injury can be described by such terms as: foreign body in eye, cut, puncture, bruise, sprain, strain, fracture, burn, dermatitis, etc.
INVESTIGATION
The investigation section is completed in narrative format and consists of four parts: description of accident, cause of accident, corrective action and industrial injury verification.
Description of Accident
a. What was the employee doing at the time of the incident?
b. What sequence of events led to the incident
c. What were the working conditions and tools being used?
d. Any witnesses or contributors to the incident?
e. How did the accident happen?
f. Some types include:
i. Struck against
ii. Struck by an object
iii. Caught in or between
iv. Slipped
v. Tripped
vi. Overexertion
vii. Inhaled
viii. Absorbed
ix. Ingested
x. Contact with electric current
Cause of Accident
a. Causes include unsafe acts or equipment as well as poor or improper training.
b. Other possible causes may include:
i. Improper instruction
ii. Lack of skill
iii. Operation without authority
iv. Horseplay
v. Physical impairment
vi. Failure to warn or secure
vii. Failure to lockout
viii. Unsafe position or speed
ix. Improper protective equipment
x. Poor housekeeping
xi. Unsafe arrangement
xii. Hazardous condition
xiii. Unsafe process or procedure
xiv. Unsafe lifting or carrying
xv. Poor ventilation or lighting
xvi. Improper guarding
xvii. Improper maintenance
xviii. Improper safety device
xix. Improper tool
xx. Chemical spill
xxi. Lack of time
xxii. Work overload
xxiii. Failure to inspect
xxiv. Failure to enforce
xv. No inspection made
xxvi. Failure to train
Corrective Action Taken or Recommended
This section describes the corrective action that the supervisor has taken or will take to prevent similar accident from occurring. This may require action from other departments such as PPM for repairs or EH&S for training.
Industrial Injury?
This is where the supervisor verifies that the injury occurred while the employee was on the job and covered by Workers’ Compensation. If the supervisor believes that the injury did not happen during the course of employment, an explanation is necessary.
TREATMENT DATA
This section details the treatment provided and who provided it. Note if the employee is off work because of the accidental injury and how long the employee will be off. Is modified duty available for the injured employee to return to work?
The supervisor must sign and date the report.
MISCELLANEOUS
• Examine the accident site and preserve the scene if necessary.
• Take photos or make a diagram if it helps explain the situation.
• Remove/repair unsafe conditions.
• Interview witnesses as necessary.
• Be sure the report is legible.
• Use additional pages as required.
CALL ENVIRONMENTAL SAFETY & HEALTH (818) 677-2401
• For serious injuries or requiring overnight hospitalization.
• For any injured employee transported off campus for medical care.
• For assistance with the investigation.
• When in doubt.
If you have any questions regarding the completion of this report, please call Environmental Safety & Health on extension 2401.