This document is a supervisor's incident investigation report for a workplace injury. It collects information about the injured employee, including name, age, occupation, date and time of incident, location, witnesses, and nature of injuries. It also identifies potential causes of the incident such as poorly maintained equipment, unsafe behaviors, or failure to follow safety procedures. The supervisor describes actions that could be taken to prevent similar incidents in the future. Signatures are required from the supervisor, safety responsible person, and manager.

1. Supervisor’s Incident Investigation Report(Sample #1)<br />for Workplace Injuries<br />1.Name of employee Age <br />2.Occupation Dept. & No. <br />3.Date of incident Time A.M. P.M. <br />4.Place of incident <br />5.Witness(es) <br />6.Did you authorize first-aid or doctor?symbol 48 \f \"
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\s 110 Yessymbol 48 \f \"
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\s 110 No<br />Name and address of doctor <br />7.Did injured leave work?symbol 48 \f \"
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\s 110 Yessymbol 48 \f \"
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\s 110 NoWhen <br />8.Did injured return to work?symbol 48 \f \"
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\s 110 Yessymbol 48 \f \"
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\s 110 NoWhen <br />9.Describe nature and extent of injuries <br />10.Describe incident <br />11.Accident causes (mark those that apply)<br />Physical Sources<br />symbol 48 \f \"
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\s 110Poorly maintained tools or equipment<br />symbol 48 \f \"
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\s 110Poor housekeeping, slippery floor, or tripping hazards<br />symbol 48 \f \"
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\s 110Unguarded equipment<br />symbol 48 \f \"
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\s 110Crowded work conditions<br />symbol 48 \f \"
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\s 110Poor storage practices<br />symbol 48 \f \"
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\s 110Personal protection and clothing not adequate for hazards<br />symbol 48 \f \"
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\s 110Insufficient lighting or ventilation<br />symbol 48 \f \"
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\s 110Cold or hot temperatures<br />symbol 48 \f \"
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\s 110Other contributing conditions<br />Unsafe behaviors<br />0Inadequate instructions<br />0Did not use assigned personal protective equipment<br />0Did not follow rules or instructions <br />0Circumvented safety features<br />0Used poorly maintained tools and machinery<br />0Failed to follow established procedures and work practices<br />0Unable to physically perform work<br />0Other contributing behaviors<br />12.Describe actions to take to avoid recurrence: <br />13.Signatures:<br />14.Prepared By:<br />(Supervisor)<br />Reviewed By:<br />(Person Responsible for Safety)<br />(Manager)<br />Date:<br />(Must be completed within 24 hours of incident)<br />- Company Use Only -<br />