SUPERVISOR’S NEAR-MISS INVESTIGATION REPORT
Step
1
of
3
33%
Project Name
*
Contractor/Employer
*
Accident Date
*
MM slash DD slash YYYY
Accident Time
*
:
Hours
Minutes
AM
PM
AM/PM
Date Reported
*
MM slash DD slash YYYY
Accident location
*
Injured Employee
*
How long at present assignment?
*
Lost time expected
*
What was the employee doing when accident occurred?
*
How did the injury occur?
*
What object or substance affected the employee?
*
Describe injury in detailed (Body part, ect.)
*
Any previous or similar injuries?
What caused this accident?
*
Additional factors involved:
Failure to obey safety rule?
*
Yes
No
Failure to use safety device?
*
Yes
No
Intoxication/Alcohol/Drugs?
*
Yes
No
Other
Reprimand given
1st Written
*
Yes
No
2nd Written
*
Yes
No
Terminated
*
Yes
No
Corrective action taken?
*
Name of witness?
First aid by?
Name of doctor/hospital
Supervisor
*
Project manager
*
General foreman
*
Signature Employee refuses medical treatment
Start typing and press Enter to search
