Supervisor’s Report of Accident Exposure

Every accident has a cause and most can be prevented.

Profit from your experience and investigate every accident, regardless of whether injury results, and correct the conditions responsible before they cause other accidents.

An accident is any occurrence from which bodily injury or damage to property may result, regardless of whether any injury or damage does result.

All accident causes are subject to control. The following are some of the basic causes of accidents:

 

Employee Characteristics

·       Haste, short cuts, and taking chances

·       Guards provided but not used

·       Personal safety devices furnished, but not used

·       Improper or unsafe tool or equipment used

·       Horseplay or fooling around

·       Instructions or rules disregarded

·       Inattention

·       Inexperience

·       Physical condition

·       Improper body position

·       Improper method of doing work

·       Action of fellow worker

·       Improper clothing

 Supervisory

·       No instructions given

·       Incomplete instructions

·       Rules, standards, or instructions not enforced

·       Personal safety devices not provided (goggles, safety belts, safety hats, safety shoes, masks, respirators, etc.)

·       Proper or safe tools or equipment not provided

·       Inadequate inspection of equipment or workplace

·       Improper procedure in doing work

·       Poor job planning

·       Haste

·       Improper training
Equipment or Materials

·       Ineffectively guarded equipment

·       Unguarded equipment

·       Defective tools

·       Defective material

·       Defective equipment (not motor vehicles)

·       Improper type or poorly designed equipment or materials

·       Unsafe equipment or material of others than employer

 Unsafe Conditions

·       Poor light

·       Poor ventilation

·       Congestion

·       Improper piling or storing

·       Exits or emergency escapes inadequate or not provided

·       Faulty layout of plant or facilities

·       Tools, equipment, or materials scattered around

·       Slippery floors

·       Unsafe conditions caused by someone other than employer or employee
Preventing Accidents

·         Save your copies of the accident reports

·         Compare accident causes periodically

·         Determine the most frequently occurring cause

·         Eliminate the common accident causes

 

Supervisor’s Report of Accident/Exposure
Employer
Division
Name of Injured
Occupation
Part of Body Injured
Hour a.m.-p.m.
Name and Address of Physician
Nature of Accident Exposure
Did Injured Leave Work?
Was Injured Acting in Regular Line of Duty?
Where Did the Accident Occur?
What Steps Should Be Taken to Prevent a Similar Accident?
Date
Supervisor’s Signature
 

Any person who makes or causes to be made any knowingly false or fraudulent materials statement or material representation for the purpose of obtaining or denying workers’ compensation benefits or payments is guilty of a felony.

 

This report does not satisfy an employer’s obligations to report work related injuries to your workers’ compensation insurance carrier or to Cal/OSHA.