EmailMeForm
Please notify Human Resources at (603) 437 - 0200 as soon as reasonable when a workplace incident occurs. When possible, please complete this form and submit it the same day as the incident and never more than 24 hours from the date of the incident. Cafe Services, Inc. requires that this supervisor's review accompany the internal report of injury whenever an employee is injured through the course of their work. It is imperative that this report is completed by the supervisor of the impacted employee. The information you provide is essential to complete the First Report of Injury and in evaluating the root cause of an incident.
General Information
Name of person completing this form:
First
Last
Name of injured or impacted employee:
First
Last
Your best contact number:
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Division:
Please select
Corporate Dining
Fresh Picks
Glendale Senior Dining
Camps
Location:
*
Please select
HQ 0
100 Light St
1414 Mass Ave 266
AAA 556
ABB 504
Amazon Robotics 215
Amazon Westborough 222
Analogic 277
Arbella 237
Axcelis 209
AvanGrid Orange 180 510
AvanGrid Orange 100 511
AvanGrid East Hartford 512
AvanGrid Binghamtpn 472
AvanGrid Augusta 570
AvanGrid Portland 571
Baupost 211
Bedford Business Park 236
Belden 476
BIC 506
Brighton Marines 255
Cabot Cafe 263
Cafe 50 217
Cafe 51 225
Cafe 200 218
Cafe 900 208
Cell Signal 242
Cell Tozer 249
CityPoint 221
CAES 310
Comcast Berlin 508
Colt 513
Comcast Boot PA
Comcast Manchester 303
Comcast Hudson 314
Comcast New Castle 551
Comcast Newark 552
Community Campus 315
Crown Colony Cafe 243
CPI 257
Eastern Bank 245
Flanders 260
AJ Nonwovens 316
GE 318
GEM Group 212
GSC 505
Hanover Howell 460
Hanover Worcester 264
Invista 553
Insight 304
Jordan's Furniture 223
M/A Com 241
National Grange 305
NHBB 302
NYISO 470
PTC 233
Riverbend 509
Schneider 213
Schneider Foxboro 256
Spit Brook 309
Southco
Talbots 230
Tara Cafe 313
TEVA 485
Verizon 244
Timberland 319
Timken 312
Timken Lebanon 317
Waterfall 231
Wayside Cafe 210
WB Mason 253
Wellesley 251
Westborough Park 621
WR Grace 452
830 Winter Street 252
930 Winter Street 207
850 Winter Street 206
Location:
*
Please select
Asst. Living Center of Salisbury 202
Back Bay 122
Belknap County 114
Bennington 115
Bowman Place 117
Bradley House 400
Carroll Center for the Blind 207
Charles River Recovery 214
Davenport 211
Fernside 215
Fitch Home 200
Gatewood Manor 100
Golden Pond 209
Juniper Hill Village 509
Ledgeview 111
Leeway 505
Liberty Health 112
Manchester Housing Authority 503
Maplewood 102
McLean Naukeag 216
Meals on Wheels 113
Meetinghouse 103
New London Hospital 121
Ocean View 300
Peabody Place 119
PITKAT - VHA 500
Presidential Oaks 123
Rockingham Assisted Living 125
Rockingham County Nursing Home 106
SCAAD 506
Scandinavian Living Center 201
Scott Farrar 109
Serenity- 206
Silverbrook Estates 504
Simsbury Housing Authority 501
Smithfield Gardens - 507
Strafford County MOW 120
Sugar Hill 118
Taylor Home 110
The Eleanor 510
Vernon Green 402
Water Tower 107
Wediko 124
Wentworth Senior Living 101
Windsor Place 210
Woodside 111
Location:
Please select
Ashland 136
Barrington 123
Bethlehem 140
Boston Prep 202
Campton 132
Claremont 160
Conval 142
Dover 134
The Eleanor 510
Farmington 137
Fremont 117
Granby 400
Gardner 206
Greenland - 154
Hampstead 113
Hanover 121
Henniker 146
Hull 205
Holderness 148
Kearsarge 130
Lafayette 139
Lebanon 105
Lempster 145
LinWood 108
Longmeadow 700
Lyme 157
Mascenic 127
Marion Cross 121
Mascoma 100
Milton 138
Moultonborough 101
Newmarket 155
Newport 122
North Middlesex 203
Northwood 120
Pittsfield 103
Plymouth 125
Profile 111
Ray School 153
Rumney 128
Rutland 163
Sanborn 110
Somersworth 118
Strafford 159
Rollinsford 119
Newfound 131
Weare 102
Wentworth 104
Rochester 156
Winchendon 207
WSESU 307
Specific Location of Incident - Example, HS, MS, ES, Satellite Account. Insert N/A if not applicable.
*
District Manager:
Please select
Feeley
Minnon
Henrique
Corley
Poppers
Wolters
District Manager:
Please select
Brustein
Decourcy
Gallagher
Harrington
Hecker
Martineau
District Manager:
Please select
Faro
Gillespie
Green
Rumbolt
Sullivan
Date of incident:
*
MM
/
DD
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YYYY
Time of incident:
*
HH
:
MM
AM
PM
AM/PM
Date and time you were first notified of the incident (if different):
MM
/
DD
/
YYYY
HH
:
MM
AM
PM
AM/PM
Was there any delay in the reporting of this incident?
*
Please select
Yes
No
Please list the reason(s) for the delay in reporting this incident:
*
Type of Reporting:
*
911 Call
Dr. Visit/Occ Health
ER
First Aid
Reporting Only
Supervisor Findings
A description of the section goes here.
Please describe below the area(s) of the body you were informed have been injured as a result of this incident (for example "right hand", "left foot", "forehead", etc.):
*
Please use the space below to best describe the occurrence and make sure to be very specific by including what tasks were being performed when pain was first noticed/injury occurred, the exact location of the incident, and what equipment was being used.
*
Was the employee wearing appropriate Personal Protective Equipment?
*
Please select
Yes
No
N/A
Please explain why the employee was not wearing the appropriate Personal Protective Equipment:( If no PPE was necessary, please write N/A)
*
Personal Protective Equipment
Cut glove
Safety Glasses
Slip Resistant Shoes
Slicer Cover
Safety Box Cutter
OSHA Compliant Step Ladder
Not Applicable
Select option that applies to incident - For example, you would not select Slip Resistant Shoes for a burn or repetitive motion injury
To your knowledge, is this an aggravation of a previous injury or condition?
*
Please select
Yes
No
Please provide details of previous injury or condition below:
*
The root cause of this incident has been found to be:
*
From a supervisors point of view, was the injury/incident caused by an unsafe act, an unsafe condition, lack of training or undetermined? (Check all that apply)
ACTIONS
*
Horseplay
Failure to follow established policy/procedure
Operation equipment or tools without proper training
Moving too quickly
Circumvented safety device
Failure to use right tool for the job
Not wearing or using personal protective equipment (PPE)
Working in an environment not conducive to work function
Failure to ask for or did not receive assistance
None
Please leave detailed comments further describing what you have selected from above:
*
Did equipment contribute to incident?
Yes
If yes, please indicate factors that lead to incident, i.e. age of equipment, defective equipment, improper installation, etc.
*
No
CONDITIONS
Building repair issues
Defective or inadequate equipment
Fire hazard
Inadequate guarding/safety devices
Inadequate or improper storage
Insufficient lighting
Negative or unsafe personal attitude
Poor visibility
Spilled Liquid/ Food Debris
Tight workspace
Unmarked/Unidentified building hazards
Please leave detailed comments further describing what you have selected from above:
SYSTEM
Improper/inadequate supervision
No training/ineffective training
Employee could not perform the job (ineffective hiring/placement standards)
Improper or lack of policy/procedure
Failure to establish or enforce safety rules
Tolerance of unsafe conditions
Inadequate or lack of preventative maintenance
Inadequate purchasing standards (inferior tools or equipment)
Failure to provide appropriate warnings/signage
Poor job design
Conflicting motivations (time/quality/cost/safety)
Please leave detailed comments further describing what you have selected from above:
Was any property damaged as a result of this incident?
*
Please select
Yes
No
If yes, please note the damage below:
*
What, if any, other details should be noted?
Corrective Actions (those that have been or will be taken, to prevent recurrence):
RE-TRAINING
*
Unneccessary
Necessary
If re-training is necessary, it is necessary for:
Employee Only
Job Specific
Department
Facility Wide
What actions have been taken to remove or reduce hazards that led to or mitigated this incident?
Do you have information from a witness you would like to include in this report?
*
Please select
Yes
No
Name of witness:
First
Last
Phone:
###
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###
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####
Best time to contact:
Please select
AM
PM
Job Title (Description)/Dept.:
Attach Witness Statement Here
If unable to attach witness statement please detail their comments here:
Attach scanned "Employees Review of Incident" here.
*
Add File
Acknowledgement Statements
I have completed this report and believe the accident/incident occured as stated:
Supervisor signature
*
Clear
Email Address
*
(Email address of individual submitting this form is required for verification purposes)
Date form completed and submitted
*
MM
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DD
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YYYY