Supervisors Accident Investigation Form

For internal use only. However Cove Risk Services may request this form to gather detailed injury information.

Employee Name: ______

Date of Incident: ______Time of Incident: ______AM/PM

1. Describe the incident in full detail (mentioning the who, what, how, and why): ______

Please use backside of this page for additional space.

2. Describe any concerns with the report (accuracy): ______

3. Did the employee return to work? Yes ❏ No ❏ When?______AM/PM

4. Will the employee have work restrictions? Yes ❏ No ❏

If no restrictions proceed with plan for return to work.

Supervisors Accident Investigation Form - page 2 TYPE OF ACCIDENT/INCIDENT

❏ resident handling (elaborate on the type of transfer)

______

❏ repositioning of resident ❏ caught between ______

❏ sharp edge - laceration/cut ❏ hot surface or flame

❏ slips/trips/falls (in or outside) ❏ splash/biologic or chemical

❏ lifting material/body mechanics ❏ resident or patient aggression

❏ reaching/pushing/pulling/twisting ❏ other (e.g. lack of awareness)______

❏ struck by/against ❏ repetitive motion

❏ needlestick/sharp

TYPE OF INJURY

❏ sprain/strain ❏ fracture/break

❏ cut/laceration/puncture ❏ shock/heat stress

❏ bruise/contusion/crushing ❏ chemical/poisoning/ingestion

❏ skin rash or reaction ❏ illness ______

❏ burn ❏ other ______

5. What body part was affected? (check most appropriate)

❏ hand ❏ head ❏ leg/knee

❏ wrist ❏ face ❏ foot/ankle

❏ arm/elbow ❏ finger/thumb ❏ neck

❏ shoulder ❏ back (low/middle/upper) ❏ other ______

Supervisors Accident Investigation Form - page 3 6. Device in use at time of injury:

❏ gait belts ❏ PPE (specify) ❏ electric bed

❏ mechanical lift ❏ wheelchair brakes ❏ lockout/tag out

❏ slide sheet ❏ syringe safety device ❏ dolly/cart

❏ wheelchair/Geri chair ❏ spring load bottoms ❏ other ______

7. Did accident result from violation of safety rule or policy? Yes ❏ No ❏

Have there been other violations? Yes ❏ No ❏ If yes, date/type of disciplinary action:

______

Have you observed the employee doing this before? Yes ❏ No ❏

8. Is the employee currently subject to disciplinary action (related or unrelated)? Yes ❏ No ❏

9. Did this accident/incident involve a third party (non-employee)? Yes ❏ No ❏

(Notify workers’ compensation of the company name, product, equipment, tool or other person.)

10. How could this accident/incident have been prevented?

______

Supervisors Accident Investigation Form - page 4

11. What are the corrective actions to prevent future accidents/incidents of this kind? ______

Ensure that all sections are complete (detailed where applicable) and attach witness statements, etc.

Date: ______Supervisor Name (Printed): ______

Injured Employee Description of Accident:

______

Date: ______Employee Name (Printed): ______

Employee Signature:

______

Supervisors Accident Investigation Form - page 5

Witness Description of Accident: ______

Date: ______Witness Name (Printed): ______

Witness Signature: ______