Supervisor's Statement

Supervisor Statement

To be used following a work related accident/incident
Date of Supervisor's Report

MonthDayYear
Supervisor's Name

First NameLast Name
Job Title or occupation
Supervisor's E-mail Address
Name of Employee involved in Accident/Incident

First NameLast Name
Employee's Email
example@greenville.edu
Date/time employee reported incident to supervisor

MonthDayYearHourMinutesAM/PM Option

Preventive Action Plan
Instructions

List the root cause(s), or reason(s) why the incident occurred (identified from Analysis). For each root cause, identify a preventive action (things that supervisor or employee will do to prevent the incident from occurring again).
Root Cause #1
Preventive Action to be taken for root cause #1
Assigned to
Employee Name Handling Preventive Action
Target Completion Date

MonthDayYear
Root Cause #2
Preventive Action to be taken for root cause #2
Assigned to
Target Date

MonthDayYear
Root Cause #3
Preventive Action to be taken for root cause #3
Assigned to
Target Date

MonthDayYear
Root Cause #4
Preventive Action to be taken for root cause #4
Assigned to
Target Date

MonthDayYear
Root Cause #5
Preventive Action to be taken for root cause #5
Assigned to
Target Date

MonthDayYear

Supervisor Certification - By clicking Submit the supervisor (or designee) certifies that the information provided is true and correct to the best of the supervisor's (or designee's) knowledge
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Supervisor Statement