Supervisor Accident Report Form

OSP FORM 300SUPERVISOR’S ACCIDENT/INCIDENT INVESTIGATION REPORTFILE NO.: DATE: / /Date of Accident: / / Time of Day : AM : PMDate Reported: / / Accident Occurred On Employer’s Premises?: Yes NoSupervisor’s Name: Telephone No.: ( ) -Dept./Univ.:Division:Location of Accident (specify site within facility):Address:City:Witnesses Name: Day Telephone Number: ( ) -Witnesses Name: Day Telephone Number: ( ) -PERSONAL INJURY1. Name of Injured:2. Social Security #: xxx-xx- Home # ( ) - Work #: ( ) -3. Home Address:4. Sex: Male Female 5. Age: 6. Job Title:7. Employment Date: / / 8. Hrs Wrk Day: Hrs Wrk/Week:9. Time on Current Job: (yrs) (mos) Full-time Part-time Temporary SeasonalEmployee Required: First-Aid Only Medical Treatment Fatality / / (date of death) OSHA RecordableEmployee Disposition StatusReturned to Work Sent HomeTo Doctor To HospitalOther Explain:PROPERTY DAMAGE Does not apply Major Serious Minor[ ] Vehicle [ ] Equipment [ ] Private PropertyVehicle I.D:.Model: Age: (yrs) (mos)Equipment I.D.:Model: Age: (yrs) (mos)Driver’s License #:Name & Title of person with most Employee Description of Accident/Incident:direct responsibility for employeeinvolved in this accident:IMMEDIATE CAUSE(s)EquipmentEnvironmentHazardous ConditionsPersonnelMgt.Unsafe ActExplain:BASIC CAUSE & CONTRIBUTING FACTOR(s)Environmental conditions PersonnelHazardous conditions ManagementLack of safety instruction & trainingCORRECTIVE ACTION:I have taken the following:Temporary / Permanentimmediate actions to reduce recurrenceExplain:Explain:I recommend the following actions(s)to prevent recurrence; and anticipatecompletion by: / / dateManagers Comments: (Appropriateness of Cause & Corrective Action)Signature:___________________________________Title:Telephone: ( ) - Date: / /Corrective Action/Follow upBy Department Manager/Safety Officer:Date: / /Reviewed by Director: Date: / /Distribution: Director, WC Administrator, Safety & Health DirectorCOMPLETE FOLLOWING CHECKLISTS

OSP FORM 300ACCIDENT OR INCIDENT BREAKDOWN BY CHARACTERISTICNATURE OF INJURYNo Physical InjuryAmputationAngina Pectoris (Heart Disease)Burn (heat, chemical)ConcussionContusion (bruise, hematoma)CrushingDislocation (nerve, disc, tear)Electric Shock (electrocuted)EnucleationForeign Body (lint in eye)FractureFreezing (frost bite)Loss of Hearing (traumatic)Heat ProstrationHernia (from lifting)InfectionInflammationLacerationMyocardial InfarctionPoisoning (not cumulative)Puncture (needle stick)RuptureSeveranceSprainStrainSyncope (fainting, etc.)AsphyxiationVascular (includes strokes)Vision LossAll Other Specific InjuriesDust DiseaseAsbestosis (lung disease)Black Lung (coal)Byssinosis (cotton)Silicosis (silica dust)Respiratory DisordersPoisoning - chemicalPoisoning - metalDermatitis (any skin irritation)Mental DisorderRadiation (tissue, bones, etc.)Other Occupational DiseasesLoss of HearingInfectious DiseaseCancerAIDSVDT Related DiseaseMental StressCarpal Tunnel SyndromeOther Cumulative InjuriesMultiple Physical Injuries OnlyMultiple Injuries, Physical & Psych.PARTS OF BODY AFFECTEDHeadSkullBrainEar(s) (eardrum)Eye(s)NoseTeethMouth (lips, tongue, throat)Facial Soft TissueFacial BonesNeck (multiple injuries)VertebraeDisc (neck, spinal column)Spinal CordLarynx (vocal cords)Soft Tissue (neck)TracheaUpper ExtremitiesUpper Arm (humerus)Elbow (radial head)Lower Arm (forearm)WristHand (excluding wrist, fingers)ThumbShoulder(s) (armpit, rotator cuff)Wrist(s) & Hand(s)Trunk (combination parts)Upper Back (thoracic area)Low Back (lumbar etc.)Disc (back)Chest (ribs, sternum etc.)Sacrum & CoccyxPelvisSpinal CordInternal OrgansHeartLower ExtremitiesHipThigh, Upper LegKneeLower LegAnkleFootToeGreat ToeLungsAbdomenButtocksLumbar & or Sacral VertebraeArtificial ApplianceInsufficient Info to IdentityNo Physical InjuryMultiple Body PartsBody SystemsTYPES OF ACCIDENTSA. Burn or Scald-Heat or Cold Exposure:ChemicalsTouched Hot PanTemperature ExtremesFire or FlameBoiling Water SplashedDust, Gases, Fumes etc.Caught in, Under, or BetweenWelding Flash - Injury to EyesRadiationContact with, NOCCold Objects/SubstancesAbnormal Air PressureElectric CurrentB. Caught In, Under or Between:Machine or MachineryCaught, In, Under or BetweenCollapsing Materials (earth slides)C. Cut, Puncture, Scrape:Broken GlassHand Tool, UtensilObject Being LiftedPowered hand ToolCut, Puncture, ScrapeD. Fall, Slip or Trip:Fall From Different LevelFall From LadderFall From Liquid/GreaseFall Into OpeningFall on Same LevelSlipped, Did Not FallFall, Slip or TripIce or SnowStairsE. Motor Vehicle:Crash of Water VehicleCrash of Rail VehicleCollision w/other VehicleCollision w/fixed ObjectCrash of AirplaneVehicle Upset (overturned)Motor Vehicle, NOCF. Strain:Continual NoiseTwistingJumpingHolding or CarryingLifting (including patients)Pushing or PullingReaching (overhead)Using Tool or MachineStrain of InjuryThrowing or WeldingRepetitive Motion (CTS)G. Striking Against or Stepping On:Moving Machine PartsObject Lifted or HandledStanding, Scraping OperatorStationary ObjectStepping on Sharp ObjectStriking or SteppingH. Struck or Injured By (kicked, stabbed,bit):Fellow Worker, PatientFalling or Flying ObjectHand Tool or MachineMotor VehicleMoving Parts of MachineObject Lifted or HandledObject Handled by OthersStruck or InjuredAnimal or InsectExplosion or Flare BackI. Rubbed or Abraded By:Repetitive MotionRubbed or Abraded, NOCDistribution: Director, WC Administrator, Safety & Health Director

Hazardous ConditionInadequate VentilationInsufficient WorkspaceImproper IlluminationEnvironmental HazardUse of Inherently Hazardous MaterialUse Inherently Hazardous Method orProcedureUse of Inadequate or ImproperTools or EquipmentInadequate Help for Heavy LiftingImproper Assignment or PersonnelHazardous Methods or ProceduresImproperly PlacedInadequately SecuredUnguarded, MechanicalInadequate ShoringUngroundedUninsulatedUncovered Connection Switches, etc.Unshielded RadiationInadequately Guarded, NECPublic Hazards (off State Premises)Traffic HazardsHazardous Condition, NECUndetermined-Insufficient InformationNo Hazardous ConditionUnsafe ActCleaning, Oiling, Adjust MovingEquipmentWelding/Repairing of EquipmentWithout SupervisorWorking on Electrically ChargedEquipmentFailure to Secure or WarnFailure to Shut off Equipment Not inUseFailure to Place Warning Signs &SignalsReleasing or Moving Loads, etc.,Without Giving Adequate WarningHorseplay, Fighting, etc.Use of Equipment or Material forOther Than its Intended PurposeOverloadingGripping Object InsecurelyTaking Wrong Hold of ObjectUsing Hand Instead of ToolsInattention to Footing or SurroundingsDisconnecting or Remaining SafetyDevicesReplacing Safety Devices WithThose of Improper CapacityJumping From Elevations, Vehicles,etc.RunningThrowing Material or ToolsRiding in Unsafe PositionUnnecessary Exposure UnderSuspended LoadsUnnecessary Exposure to MovingMaterials or EquipmentDriving Too Fast or Too SlowlyEntering/Leaving Vehicle on TrafficSideFailure to Signal When Stopping,Turning or BackingFailure to Yield ROWBacking Without Looking forClearanceFailure to Obey Traffic Control Signsor SignalsFollowing Too CloseOther (Explain)Supervisory ActivitiesInadequate Training of EmployeeFaulty Instruction to EmployeeOSP FORM 300Improper Planning of JobUnsafe Procedures of JobInadequate Knowledge/LeadershipNo Supervisory FailureEmployee AttributesLack of Knowledge or ExperienceImproperly TrainedBodily DefectsLack of Respect for HazardOther Insufficient DataDWISafety Equipment in UseHard HatSafety GlassesRespiratorMovable Exhaust HoodEar ProtectionSafety ShoesLanyards & LifelinesFluorescent Vest FlagsBuoyant WorkvestChemical ApronFaceshieldsGlovesWarning & ControlSeat BeltsShoulder HarnessOther Restraining DevicesSafety EquipmentPREPARE & ATTACH SKETCH AND/ORPROVIDE PHOTOS AS NECESSARY TODESCRIBE ACCIDENT/INCIDENTDistribution: Director, WC Administrator, Safety & Health Director