Supervisor Investigation Report

SUPERVISOR INVESTIGATION REPORT
Property:
Select the property the incident took place
Name of Injured Person:

First NameLast Name
Date of Birth:

DayMonthYear
Gender:

Other
Phone Number:
Format: (000) 000-0000.
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
What part of the body was injured?
Describe in detail
What was the nature of the injury?
Describe in detail
Describe fully how the accident happened? What was the employee doing prior to the event? What equipment, tools being using?
Describe in detail
Names of witnesses (if any):
Date and Time of Event:

DayMonthYear
Date
Hour MinutesAM/PM Option
Exact Location of Event:
What caused the event?
Describe in detail
Were safety regulations in place and used? If not, what was wrong?
Describe in detail
Did the Employee go to Doctor/Hospital?
Doctors Name:
Hospital Name:
Please upload the Certificate of Capacity

Cancelof
Recommended preventive action to take in the future to prevent reoccurrence:
Supervisors Name:
General Managers Name:
General Managers Email:
A copy of this report will be sent to this managers email upon clicking Submit. PLEASE NOTE: If you are unsure please select chris@saltwaterproperties.com
Signature of person completing report:
Please verify that you are human:
Should be Empty:

SUPERVISOR INVESTIGATION REPORT