SUPERVISOR’S INVESTIGATIVE REPORT INSTRUCTIONS

Please be sure to read the instructions before filling out this form.

GENERAL INFORMATION: This form is to provide an objective summary review of what led up to the incident
for use in an accurate investigation. Use your powers of observation when describing the incident. Fill out this
form completely and write N/A in any blanks. Attach a separate piece of paper for any information that needs
additional room. Be sure to include the employee’s name and date of injury on this piece of paper along with any
other additional information.

II. WITNESSES: Ask who, what, when, where, how and why. Find out the details of what the employee told the first
person about what occurred. What body part was injured? Did the first person observe or inspect the scene or
environment of the incident? What did they see or hear?

III. WHERE DID INCIDENT OCCUR?: Be very specific; give location, room number, etc.

IV. SEQUENCE OF EVENTS & RISK FACTORS INVOLVED IN INCIDENT: The Supervisor is to do a complete
investigation — ask who, what, when, where, how and why. Write down all the details of how the employee was injured,
what they were doing leading up to and during the incident, whether they followed protocol and what was observed at
the scene of the incident. Ask the employee to re-demonstrate so that you can clearly understand what the employee was
doing. Include details, (for example, the weight and placement of an object or a 180# resident in a custom wheelchair.)
Enter in this space the accurate sequence of events and all of the contributing risk factors so that you can develop an
effective Corrective Action Plan. Do not restate the initial description of the event!

Below is a Sample list of Contributing Risk Factors. (This is not an all inclusive list. Please consider this list as you
look at your particular situation.)
Conditions
 Unsafe Equipment
 Broken
 Safety devices lacking, broken or
altered
 Unsuitable design
 Not maintained
Acts & Behaviors
Failure to follow Safety Procedures
 Failure to use PPE properly
 Failure to obtain assistance
 Improper technique
 Using equipment unsafely
 Improper choice of tool or equipment
 Unsafe body mechanics
 Inappropriate dress or footwear
Poor lighting Inadequate ventilation
Hazardous process Weather conditions
Poor Ergonomic set up Excessive noise
Poor housekeeping: Condition of Building
 Clutter  Other (e.g. floor, wall, stairs, elevator)
 Wet/dirty floor Existing Hazards (e.g. Chemical, Fire)
Failure to recognize unsafe condition
Failure to respond to or poor judgment in responding to an unsafe condition
Performing task without knowledge/failure to ask
Inattention/distraction
Working at unsafe speeds, rushing
Horseplay
Failure to use Lock Out Tag Out properly

If applicable, include the Date of Last Attendance at: Body Mechanics Training or Aggressive Behavior Management
Training.

V. CORRECTIVE ACTION PLAN: From the Risk Factors identified above, identify specific action items needed to
be taken for each Risk Factor. For example: factors such as “acts and behaviors” may require training and monitoring
while “conditions” may require change in procedure, work order or purchase order and training. Supervisor is
responsible for communicating any corrective action needed to the appropriate person.

VI. SIGNATURES: Obtain signatures in the following order:

1. As the Supervisor filling out the form, sign and date it when complete, then….
2. Have the Administrator review, sign and date the form within 24 to 48 hours of the incident, (signature of
Administrator indicates that a thorough investigation was completed)

)
 SUPERVISOR’S INVESTIGATIVE REPORT
This is a follow-up report used to identify and correct conditions or practices, which have led to
an employee, work-related incident.
I. GENERAL INFORMATION
Facility Name Department

Employee Name Date & Time of Incident

Supervisor Completing This Form Date & Time Supervisor Notified

II. WITNESSES Remember to complete the Witness Statement Form

Name of First Person Notified Date & Time Person was Notified

Other Witnesses

III. WHERE DID INCIDENT OCCUR?

IV. SEQUENCE OF EVENTS & RISK FACTORS INVOLVED IN INCIDENT See Contributing Risk Factors on page 1

Was a third party responsible for the incident? If yes, list name, address & phone.
Was a machine part involved? If yes, describe.
Was the machine part defective? If yes, in what way?

V. CORRECTIVE ACTION PLAN

Retraining, what & when? Person responsible Date referred

Monitoring of work practices

Work or Purchase orders written

Procedures & Process revised

Referrals

VI. SIGNATURES
Signature of Supervisor Completing Form Date Completed

Signature of Facility Administrator Date Reviewed by Facility Administrator

Signature of Safety Committee Chairperson Date Signed by Safety Committee Chairperson

VII. IMPORTANT If equipment or machinery was the cause of the incident, remove the equipment immediately from
harm’s way. Contact: Director of Health & Safety.
D O N OT F IX O R R EPLACE F AULTY O R D EFECTIVE E QUIPMENT W ITHOUT F IRST C ONTACTING A SAFETY
CONSULTANT.