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Supervisor Incident Report
*To Be Completed by the Employee’s Supervisor Immediately after
Incident and emailed to [email protected]
Supervisor & Incident Information Supervisor’s Name: Project Manager: Jobsite Name:
Division: Commercial Service Solar ECSI Rochester Duluth National Other:
Injured Employee’s Name: Date/Time of Incident: To Whom and When was Incident Reported:
If the incident was reported late, please explain why:
Type of Incident: Near Miss Equipment/Property Damage First Aid Injury , Injury Beyond First Aid Restricted duty Loss Time
Medical Treatment: (Include treatment center name or reason for refusal of treatment) (Keep a copy of Employee Work Ability Report) First Aid (Onsite) Star Triage WorkCare Medical Center
Emergency Room Refusal of Treatment
Describe Bodily Injury Sustained: (Sprain, cut, pulled muscle, etc.. Be specific about body part(s) affected)
What was the employee doing when the incident occurred?
What was the work direction for the task? Who assigned him to perform the task? (if applicable, attach the JHA or pre-task plans)
Causes Why did this incident occur? (Root Cause Analysis)
Man: Method: Machine: Material: Mgmt:
Supervisor Incident Report
*To Be Completed by the Employee’s Supervisor Immediately after
Incident and emailed to [email protected]
Was the employee trained on the proper safety procedures/use of PPE?........................................... Yes No Was the employee cautioned for failure to follow proper safety procedures/use of PPE?…………..….. Yes No
Did the employee promptly report the incident?................................................................................. Yes No Employee’s Work Status …….. RETURNED TO WORK DID NOT FINISH SHIFT LOST WORK DAY LIKELY
Tools / Equipment in Use:
Personal Protective Equipment in use: Safety Glasses Gloves Hard Hat Additional:____________ (For laceration injuries to the hand, please ensure that you have the employee’s gloves)
Additional Information: (I.e. photos, timeline of events, work task for the day, follow-up treatment, work ability information, etc.)
Supervisor Corrective Action to Ensure This Type of Incident Does Not Reoccur? Man: Method: Machine: Material: Mgmt:
Supervisor Signature: ________________________________________ Date: ___________________
