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_Supervisor's Accident Investigation <br />(To be completed by the employee's supervisor or other responsible administrative official) <br />Location where accident occurred <br />Failure to lockout <br />Employer's Premises: <br />Job site: <br />Yes Q Nou <br />Yes No <br />Date of accident or illness <br />Who was injured? <br />_ Poor ventilation <br />_ Horseplay <br />_ Inoperative safety device <br />Employee <br />Non -Employee <br />Improper dress <br />Time of occident e.m. <br />p.m, <br />_ Unsafe equipment <br />Length of time with firm <br />Job title m occupation <br />_Unsafe position <br />Name of dept. normally assigned to <br />_ Physical or mental impairment <br />How long has employee worked atjob <br />wham injury or illness occurred? <br />What property/equipment was damaged? <br />Property/equipment owned by: <br />Wbat was employee doing whenijury/illness occurred? <br />What machine or tool was being used? <br />What type of operation? <br />How did injury/illness occur? List all objects and substances involved. <br />Pan of body affectod/injured? <br />Any prior physical conditions? <br />Yes O NoF'J <br />Ifso,what? <br />Nature and extent of injury/illuess and property damaged <br />(be specific) <br />PLEASE INDICATE ALL OF THE FOLLOWING WHICH CONTRIBUTED TO THE INJURY OR ILLNESS <br />Supervisor's corr <br />Failure to lockout <br />_ Improper maintenance <br />_ Poor housekeeping <br />_ Failure to secure <br />_ Improper protective equipment <br />_ Poor ventilation <br />_ Horseplay <br />_ Inoperative safety device <br />_ Unsafe arrangement or process <br />Improper dress <br />_ Lack of training or skill <br />_ Unsafe equipment <br />Improper guarding <br />_ Operating without authority <br />_Unsafe position <br />Improper instruction <br />_ Physical or mental impairment <br />_ Other <br />ective action to ensure this type of accident does not recur: <br />Wes employee trained in the appropriate use of Persoml Protective Equipmeot/Proper safety procedures?... Yes _ No _ <br />Was employee cautioned fot failure to use Personal Protective Equipment/Propersofety procedures? .......... Yes _ No _ <br />Didemployee promptly report the injury/illness?...:...............................................................................40.44..... Yes _ No _ <br />Is there modified duty available?...................................................................................................................... Yes No <br />Superv <br />Y-0LGLnbil <br />isor's name Supervisor's signature Phone# Date <br />Farm maybe copied as needed <br />43 <br />