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___________
4.
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.
rd
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