<p>Supervisors Accident Investigation Form</p><p>For internal use only. However Cove Risk Services may request this form to gather detailed injury information.</p><p>Employee Name: ______</p><p>Date of Incident: ______Time of Incident: ______AM/PM</p><p>1. Describe the incident in full detail (mentioning the who, what, how, and why): ______</p><p>Please use backside of this page for additional space.</p><p>2. Describe any concerns with the report (accuracy): ______</p><p>3. Did the employee return to work? Yes ❏ No ❏ When?______AM/PM</p><p>4. Will the employee have work restrictions? Yes ❏ No ❏ </p><p>If no restrictions proceed with plan for return to work.</p><p>Supervisors Accident Investigation Form - page 2 TYPE OF ACCIDENT/INCIDENT</p><p>❏ resident handling (elaborate on the type of transfer) </p><p>______</p><p>❏ repositioning of resident ❏ caught between ______</p><p>❏ sharp edge - laceration/cut ❏ hot surface or flame</p><p>❏ slips/trips/falls (in or outside) ❏ splash/biologic or chemical</p><p>❏ lifting material/body mechanics ❏ resident or patient aggression</p><p>❏ reaching/pushing/pulling/twisting ❏ other (e.g. lack of awareness)______</p><p>❏ struck by/against ❏ repetitive motion</p><p>❏ needlestick/sharp</p><p>TYPE OF INJURY</p><p>❏ sprain/strain ❏ fracture/break</p><p>❏ cut/laceration/puncture ❏ shock/heat stress</p><p>❏ bruise/contusion/crushing ❏ chemical/poisoning/ingestion</p><p>❏ skin rash or reaction ❏ illness ______</p><p>❏ burn ❏ other ______</p><p>5. What body part was affected? (check most appropriate)</p><p>❏ hand ❏ head ❏ leg/knee</p><p>❏ wrist ❏ face ❏ foot/ankle</p><p>❏ arm/elbow ❏ finger/thumb ❏ neck</p><p>❏ shoulder ❏ back (low/middle/upper) ❏ other ______</p><p>Supervisors Accident Investigation Form - page 3 6. Device in use at time of injury:</p><p>❏ gait belts ❏ PPE (specify) ❏ electric bed</p><p>❏ mechanical lift ❏ wheelchair brakes ❏ lockout/tag out</p><p>❏ slide sheet ❏ syringe safety device ❏ dolly/cart </p><p>❏ wheelchair/Geri chair ❏ spring load bottoms ❏ other ______</p><p>7. Did accident result from violation of safety rule or policy? Yes ❏ No ❏ </p><p>Have there been other violations? Yes ❏ No ❏ If yes, date/type of disciplinary action:</p><p>______</p><p>Have you observed the employee doing this before? Yes ❏ No ❏</p><p>8. Is the employee currently subject to disciplinary action (related or unrelated)? Yes ❏ No ❏</p><p>9. Did this accident/incident involve a third party (non-employee)? Yes ❏ No ❏ </p><p>(Notify workers’ compensation of the company name, product, equipment, tool or other person.) </p><p>10. How could this accident/incident have been prevented?</p><p>______</p><p>Supervisors Accident Investigation Form - page 4</p><p>11. What are the corrective actions to prevent future accidents/incidents of this kind? ______</p><p>Ensure that all sections are complete (detailed where applicable) and attach witness statements, etc.</p><p>Date: ______Supervisor Name (Printed): ______</p><p>Injured Employee Description of Accident: </p><p>______</p><p>Date: ______Employee Name (Printed): ______</p><p>Employee Signature: </p><p>______</p><p>Supervisors Accident Investigation Form - page 5</p><p>Witness Description of Accident: ______</p><p>Date: ______Witness Name (Printed): ______</p><p>Witness Signature: ______</p>