EmailMe Form - Workplace Incident: Supervisor Review

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:

### - ### - ####

Division:

Location: *

Location:

Specific Location of Incident - Example, HS, MS, ES, Satellite Account. Insert N/A if not applicable. *

District Manager:

Date of incident: *

MM / DD / YYYY

Time of incident: *

HH : MM AM/PM

Date and time you were first notified of the incident (if different):

MM / DD / YYYY HH : MM AM/PM

Was there any delay in the reporting of this incident? *

Please list the reason(s) for the delay in reporting this incident: *

Type of Reporting: *

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 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 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 *

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

Please leave detailed comments further describing what you have selected from above:

SYSTEM

Please leave detailed comments further describing what you have selected from above:

Was any property damaged as a result of this incident? *

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? *

Name of witness:

First Last

Phone:

### - ### - ####

Best time to contact:

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. *

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 / DD / YYYY