Supervisor'S Investigation Report Form printable pdf download

SUPERVISOR’S INVESTIGATION REPORT

Of Employee On-the-Job Injury or Illness

Teleclaim 1-877-MDC-RISK (1-877-632-7475)

Is Employee ___Permanent

___Probationary

___Other __________________ Teleclaim # __________________________________________________

1. Employee Name __________________________________________________Title ______________________________________ID #_________________

2. Dept # _______ Div # ________ Location # ___________

3. Date of Incident __________________________________ Time ____________ AM or PM

3. Address & Location of Incident ___________________________________________________________ City _________________________ Zip___________

Supervisor (print) __________________________________ (signature) _____________________ Phone ________________________________________

Person Writing this Report, if different (print)______________________________ (signature)_______________________ Phone_______________________

5. Who was incident first reported to? Name _________________________________________________ Title________________________________________

Date___________________ Time____________ AM or PM Phone (s) _____________________________________________________________________

6. Was this a chemical or biological exposure? ____ Yes ____ No If yes, complete Exposure Report form

7. Was this first reported as a minor injury on the Minor Injury Log?

____ Yes

____ No Date ________________________ Time ___________ AM or PM

8. Did employee go to: ___ Clinic ___ Doctor ___ Hospital

If known, Name of Clinic, Doctor or Hospital ___________________________________________

Address __________________________________________________________________ Date _______________________ Time ____________ AM or PM

9. Did injured employee do something to cause or contribute to the incident?

_____No

_____Yes If yes, check reason item below:

____ Improper planning

_____Departure from standard procedure

_____ Inattention

______ Reckless Behavior

_____ Lack of proper skills

_____Chose to use defective or improper equipment

_____ Failed to follow instructions

______Other

Describe the above ________________________________________________________________________________________________________________

10. Did another factor contribute to the accident/injury or illness? ____No

_____ Yes

If yes, check item below:

_____Action(s) of another person

____Departure from standard procedure

____Inadequate / improper training or skill

_____Improper planning

____ Defective or improper equipment

____Inadequate /incorrect information

_____Insect/Animal

____Chemical / Biological exposure

____ Weather

______Other

Describe the above________________________________________________________________________________________________________________

11. What have you or your department done to help prevent a re-occurrence? Be specific (attach additional information if applicable) _____________________

______________________________________________________________________________________________________________________________

12. Witness Name _______________________________________ Title_________________________________ Phone ________________________________

Witness Name ________________________________________ Title_________________________________ Phone ________________________________

13. Attach supporting documents to this report such as photos, diagrams, statements or other documents. Total number of pages attached _______________

14. Employee’s Description of Incident (Use attachment if necessary. Number of pages of employee attachment ______) _____________________________

________________________________________________________________________________________________________________________________

Employee Signature (if available) _______________________________________________________________________________ Date: _______________

Failure to complete this report accurately is a violation of Miami-Dade County Policies and Procedures. Violations may result in disciplinary action.

Submit completed report to: ISD Risk Management Phone 305-375-4280, FAX 305-375-5492; 111 N.W. 1 Street, 23

Floor / Department retains copy.

Miami-Dade Office of Safety, Risk Management, ISD

For the use of the County Attorney’s Office and ISD

Supervisor'S Investigation Report Form

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