SUPERVISOR’S INVESTIGATION REPORT
COUNTY OF KERN
Injured Employee:
DOB
Last,
First
/
/
ID#
Male
Female
Initial
(
Home Address:
Street
City and Zip Code
Date Injured
Time employee started work
Time
Time
:
:
AM
AM
)
Day time phone
Dept.
PM
PM
Job Title
(Indicate Department, e.g., Probation, DA, Health)
Nature/Extent of injury:
Engaged in what work when injured?
Was employee seen by a hospital/doctor?
YES
NO
Did employee complete shift?
YES
NO
Was employee treated in an Emergency Room?
YES
NO
Was employee hospitalized overnight as an in-patient?
YES
NO
Name/Address of Doctor or hospital where employee was treated:
Street
Name of Doctor/Hospital
Number of lost
workdays
City
A.
NATURE OF INJURY
101
102
103
104
105
106
107
108
109
110
111
112
113
114
115
116
Amputation
Burns
Contusion (bruise)
Electrical Shock
Foreign Body
Fracture
Heat
Hernia
Infection
Abrasion
Bite
Laceration (cut)
Hypertension
Puncture
Strain/Sprain
Stress
PART OF BODY
201
202
203
204
205
206
207
208
209
210
211
212
213
214
215
216
217
Head (eye, nose, etc.)
Neck
Shoulder
Left
Right
Psyche/Mental Disorder
Hip
Left
Right
Arm
Left
Right
Elbow
Left
Right
Hand/Wrist
Left
Right
Finger
Upper Back
Lower Back
Leg
Left
Right
Knee
Left
Right
Ankle
Left
Right
Foot
Left
Right
Abdomen
Respiratory
ACCIDENT TYPE
301
302
303
304
305
306
307
308
309
310
311
312
313
314
UNSAFE CONDITION
Burn
Exposure
Cut/Puncture
Slip/Trip/Fall
Absorb/Ingest/Inhale
Stress (mental/heart)
Motor Vehicle
Repetitive Motion
Running or Jumping
Violence in Workplace
Struck by
Bite or Sting
Lifting Human
Lifting Object
401
402
403
404
405
406
407
408
409
410
B. WHAT HAPPENED AND WHERE DID IT HAPPEN?
Inadequate or no safety
guards
Poor housekeeping
Unsafe/defective equipment
Inadequate illumination or
noise control
Hazardous personal attire
Improper ventilation
Hazardous established
procedure
Slippery surface
Congestion, close clearance
No unsafe condition
UNSAFE ACT
501
502
503
504
505
506
507
508
509
510
511
512
Operating without auth.
Using defective equip.
Failure to use safety device
or protective equipment
Failure to make secure
Improper use of equipment
Safety rules violated
Unsafe loading, placing,
carrying, lifting
Took unsafe
position/posture
Operating at unsafe speed
Unsafe procedure
Horseplay
No unsafe act
WHAT and WHERE: Details of accident and the physical location
Witnesses:
C. CAUSE OF ACCIDENT
WHY and HOW: Acts, failures to act, and/or conditions that most directly contributed to this accident
D. CORRECTIVE ACTION
What action has been taken, will be taken, or is recommended, to prevent recurrence? (Mark “X” by those items completed.)
Supervisor’s Name (Print):
Date form completed:
Supervisor’s Signature: _________________________________________________
E. DEPARTMENT HEAD’S CONCURRENCE/COMMENTS
Department Head’s Name (Print):
Department Head’s Signature:
Review for concurrence or return for additional action.
Date
CONTRIBUTING CAUSE
(Indirect)
601
602
603
604
605
606
607
608
609
610
Minimum Training
Fatigue
Pre-existing physical
weakness
Intoxicated
Inattentive
Nervous, excitable,
impatient
Lost temper
Willful disregard of
instructions
Other person
No significant
personal factor
Page 2
SUPERVISOR’S INVESTIGATION REPORT
COUNTY OF KERN
To be used if additional space is necessary for items
B, C or D on first page
B. WHAT HAPPENED AND WHERE DID IT HAPPEN (continued from page 1)
C. CAUSE OF ACCIDENT (continued from page 1)
D. CORRECTIVE ACTION (continued from page 1)
E. DEPARTMENT HEAD’S CONCURRENCE/COMMENTS(continued from page 1).
IMPORTANT! – DISTRIBUTE TO:
ORIGINAL:
RISK MANAGEMENT LOSS PREVENTION SPECIALIST
ONE COPY: WORKERS’ COMPENSATION SERVICES
ONE COPY: DEPARTMENT SAFETY COORDINATOR
ONE COPY: DEPARTMENT FILE