RAPID REPORTS
Supervisor's Investigation Report
Company Code
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Incident Details
Date of Incident
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Time
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AM
Date Reported
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Branch
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Location of Incident
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Unit # (if applicable)
Type of Incident
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Employee Injury
Motor Vehicle
Property Damage
Equipment
Injured / Claimant & Property
Name of Injured/Claimant
Property Damaged
Employer
Occupation
Approx. Value
Photos
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Injury Information
Description of Injury
Severity of Injury
Cause of Injury
First Aid
Medical Treatment (Clinic/Hospital) returned to Work
Lost/Restricted Work Days
Fatality
Type of Injury
Part of Body
Incident Description
Description of Incident
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Witness(es)
Incident Photos
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Up to 10 photos. Phone photos are resized automatically.
Incident Analysis
Primary Cause(s)
Contributing Factors
Unsafe workplace conditions (check all that apply)
Inadequate guard
Unguarded hazard
Safety device is defective
Tool or equipment defective
Work area set-up is hazardous (i.e. power lines)
Unsafe lighting
Unsafe Conditions (i.e. weather)
Lack of needed PPE
Lack of appropriate equipment / tools
Unsafe Clothing
No Training or Insufficient Training
Other
Other (unsafe workplace conditions)
Unsafe acts by people (check all that apply)
Operating without permission
Not following safety policies, rules.
Servicing equipment that has power to it
Making a safety device inoperative
Using defective equipment
Using equipment in an unapproved way
Unsafe lifting
Taking an unsafe position or posture
Distraction, teasing, horseplay
Failure to wear PPE
Failure to use the available equipment / tools
Inadequate Training for Task/Job
Other
Other (unsafe acts)
Preventive / Corrective Actions
Preventive/Corrective Action(s)
Immediate Action Taken
Long Term Action(s)
Stop this activity
Guard the hazard
Train the employee(s)
Train the supervisor(s)
Redesign task steps
Write a new policy/rule
Enforce existing policy
Routinely inspect for the hazard
Personal Protective Equipment
Other
Other (long term)
Signatures
Supervisor's Name
Date
Supervisor's Signature
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Reviewed By
Date
Reviewed By Signature
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