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Supervisor s Review of Injury / Illness Incident TIME OF INCIDENT Every Injury / Illness Incident Report, DSS 03-133, must be reviewed / investigated by a local supervisor / manager. Part 1. Injured

How to fill out supervisors review of injury

How to fill out supervisors review of injury:

1. Start by providing basic information about the injured person, such as their name, employee ID, date of birth, and contact information.
2. Clearly describe the nature of the injury, including the body part affected, the cause of the injury, and any contributing factors.
3. Specify the date and time of the injury and where it occurred, including the specific location within the workplace.
4. Document any immediate actions taken following the injury, such as first aid administered, medical attention sought, or emergency services called.
5. If there were any witnesses to the incident, ensure their names and contact information are included in the form.
6. Explain any workplace hazards or safety issues that may have contributed to the injury, providing details about what steps should be taken to prevent a similar incident in the future.
7. Have the injured person or a representative review the completed form and sign it to acknowledge its accuracy.
8. Finally, submit the supervisors review of injury to the appropriate department or individual responsible for record-keeping and further investigation.

Who needs supervisors review of injury:

1. Human Resources department: They require the supervisors review of injury to maintain a record of workplace incidents, identify trends or patterns in injuries, and assess the effectiveness of safety protocols.
2. Workers' compensation insurance provider: The review helps determine the validity of an injury claim and aids in the claims process.
3. Health and safety committees and managers: They use this information to assess workplace risks, implement corrective measures, and monitor the overall safety of the work environment.
4. Relevant supervisors and managers: They need the review to understand the circumstances surrounding the injury, evaluate any potential liability, and implement preventive measures to ensure worker safety.

For pdfFiller’s FAQs

What is supervisors review of injury?

Supervisors review of injury is a formal evaluation conducted by a supervisor to assess the cause and circumstances of an employee's injury.

Who is required to file supervisors review of injury?

The supervisor of the injured employee is required to file supervisors review of injury.

How to fill out supervisors review of injury?

Supervisors can fill out the review by providing detailed information about the injury, including the date, time, location, and cause.

What is the purpose of supervisors review of injury?

The purpose of supervisors review of injury is to identify potential hazards in the workplace and implement measures to prevent future injuries.

What information must be reported on supervisors review of injury?

The review must include details of the injury, witness statements, safety measures in place, and any corrective actions taken.

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