Workers’ Compensation Program: Supervisor Incident Report
Important: The supervisor should complete this form immediately after the incident.
Page 1 of 2
This form can be filled in electronically by using the computer tab key to move to each field.
YMCA Name
Injured employee name:
Male
Social Security number:
Female
Date of birth:
Home Address:
PH:
Date of hire:
Job title & department:
Date of injury:
Time of injury:
Was first aid provided onsite?
Yes
No
AM
PM
Was additional medical attention sought?
Yes
No
(If applicable) Name of facility or physician that provided treatment:
Was, or will there be, a drug screen completed?
Last day worked:
Yes
No
Return-to-work date:
Scheduled workweek at time of injury
Hours:
Days per week:
Start time:
End time:
Start time:
End time:
Injured employee normal/usual schedule
Hours:
Days per week:
Witnesses to the incident
Name:
Address:
Phone:
PH:
Name:
Address:
Phone:
PH:
Name:
Address:
Phone:
PH:
Injured employee statement regarding the injury (list all circumstances and equipment involved):
Part(s) of body affected:
Type of injury or injuries:
The answers I have provided to the above questions are true to the best of my knowledge.
Injured employee signature:
Date:
Supervisor signature:
Date:
Please complete page 2 of this form (over)
THE REDWOODS GROUP WORKERS’ COMPENSATION PROGRAM FOR YMCAS
WCSIRF 5.13.09
Workers’ Compensation Program: Supervisor Incident Report (cont.)
Page 2 of 2
Please check one and only one box in each of the following sections:
SPECIFIC LOCATION OF INCIDENT
Aquatics area
Athletic / play field
Cabin / tent
Campfire / meeting area
Challenge course
Child watch / babysitting
Childcare area
Class / meeting room
Climbing wall / tower
Ex Room: aerobics, etc.
Ex Room: cardio / strength equip
Ex Room: free weights
Gym
Gymnastics facility
Lobby / halls
Locker / rest room
Parking lot / garage
Play structure or area: interior
Playground (with equipment)
Pool
Racquetball (etc.) court
Range: rifle / archery
Residence facility
Running track
Skating rink
Spa / Sauna / Steam
Stairs
Waterfront (non-pool)
Other
Childcare: Child Watch
Childcare: Outdoor Education
Childcare: Preschool / Daycare
Health & Fitness: Organized
Health & Fitness: Personal
Non-sport activities
Senior program / activity
Social Outreach (incl. residence)
Special Events / Field Trips
Sports: Adult
Sports: Informal
Sports: Youth
Other
PROGRAM NAME
Aquatics
Camp: Day / Holiday
Camp: Resident
Camp: Sports
Childcare: Before & After
GENERAL ACTIVITY
Aquatics: boating, all forms
Aquatics: all others
Animal: grooming
Animal: care
Animal: training
Baseball / Softball / T-ball
Basketball
Bicycles / Motorbikes
Class: Aerobics
Class: Kick-boxing
Class: Martial arts
Dance
Exercise: Cardio equip.
Exercise: Free weights
Exercise: Strength equip.
Exercise: Run / Walk
Exercise: Other personal
Football
Games / Structured activity
Gymnastics
Hiking / backpacking
Hockey (ice or roller)
Horseback riding
Playground equipment
Racquetball / Handball / Squash
Skateboarding
Skating (ice or roller)
Skiing / Snowboarding
Skiing / Water
Soccer
Transportation / Driving
Volleyball / Walleyball
Walking (incidental)
Other
SPECIFIC ACTION
Aggressive behavior of / by
Caught in, by, or between
Contact with / exposure to
Exertion
Fall (from, onto, into, or against)
Horseplay
Inhale / ingest
Participation / playing
Pushed / pulled / bumped
Struck by / against
Other
SOURCE OF INJURY
Aquatics facility: deck / dock
Aquatics facility: equipment
Aquatics facility: sides / bottom
Aquatics facility: body of water
Blood / body fluids
Door
Environment: sun, heat, etc.
Equipment: playground
Floor / Ground
Furniture
Insect / animal
Locker / cabinet
Object (ball / bat / toy / etc.)
Person (another)
Self
Burn / Blister
Chemical Exposure
Cramp
Cumulative Trauma.
Dislocation
Dizziness / Unconscious
Fracture / Break
Irritation / Reaction
Jam
Laceration / Cut
Pain / Soreness
Pinch / Crush
Wall / vertical surface
Other
APPARENT INJURY
Abrasion / Scratch
Amputation
Aquatic distress
Bite / Sting
Breathing shortened / Impaired
Bruise / Contusion
BODY PART  please check if applicable
Arm
Hand
Wrist
Elbow
Finger
Leg
Foot
Ankle
Knee
Toe
Shoulder
Chest
Stomach
Side
Back
Buttocks
right
left
Hip
Groin
Face
Ear
THE REDWOODS GROUP WORKERS’ COMPENSATION PROGRAM FOR YMCAS
upper
Eye
Nose
Head
Neck
Puncture
Seizure / Dysfunction
Sprain / Strain
Stress / Mind / Psyche
No visible / Apparent injury
Other
lower
Heart
Lungs
Mouth / Lips
Mind / Psyche
Teeth
None / Not applicable
Other
WCSIRF 5.13.09