SUPERVISOR’S ACCIDENT INVESTIGATION REPORT – RACKING

SUPERVISOR’S ACCIDENT INVESTIGATION REPORT – RACKINGTammy2021-12-09T15:47:44+00:00

SUPERVISOR'S ACCIDENT INVESTIGATION REPORT - RACKING

Foreman's Name(Required)

Your Email(Required)

Employee's Name(Required)

Department:

Occupation

Date of Incident

Time of Incident

Nature of Injury/Property Damage:

Object/Equipment/Substance Inflicting Injury:

Medical Treatment by:

Location of Treatment:

Description of Incident:

Contributing Factors:

Loss Severity Potential:

Probable Recurrence Rate:

Action Taken to Prevent Recurrence:

Supervisor/Manager: (Print)(Required)

Signature

Date

Investigated by:

Date

Reviewed by:

Date

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Single Source Systems

100 W 2nd St.
Peculiar MO, 64078
(816) 779-0924

Mailing Address

PO Box 357
Peculiar MO, 64078

Material Handling Installations

Email Clint
(816) 529-1495

Concrete Services

Email Jacob
(816) 419-4153

Get in Touch

Call

Schedule

Concrete

Warehouse Installation Services

SUPERVISOR’S ACCIDENT INVESTIGATION REPORT – RACKING