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SUPERVISOR’S ACCIDENT INVESTIGATION REPORT – RACKING
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2021-12-09T15:47:44+00:00
SUPERVISOR'S ACCIDENT INVESTIGATION REPORT - RACKING
Foreman's Name
(Required)
Your Email
(Required)
Employee's Name
(Required)
Department:
Occupation
Date of Incident
MM slash DD slash YYYY
Time of Incident
Hours
:
Minutes
AM
PM
AM/PM
Nature of Injury/Property Damage:
Object/Equipment/Substance Inflicting Injury:
Medical Treatment by:
Location of Treatment:
Description of Incident:
Contributing Factors:
Loss Severity Potential:
High/Major
Mediurn/Serious
Low/Minor
Probable Recurrence Rate:
Frequent
Occasional
Rare
Action Taken to Prevent Recurrence:
Supervisor/Manager: (Print)
(Required)
Signature
Date
MM slash DD slash YYYY
Investigated by:
Date
MM slash DD slash YYYY
Reviewed by:
Date
MM slash DD slash YYYY
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