subject_line
Supervisor's Report of Incident/Accident
Supervisor Name
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Supervisor Phone Number
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Supervisor Email
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Employee Name
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SSN:
Date of Birth
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Gender
*
Female
Male
Position
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Hire Date
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Employee Street Address
Employee Phone Number
City
State
*
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Washington DC
Zip Code
Incident Department
*
DVR-DWD Division of Vocational Rehab- Dept of Workforce Development
Plant 5 - Beaver Dam
DPSF DPS -Fort Atkinson
DPSW DPS - Watertown
DPSO DPS-Oconoowoc
DPSM DPS-Madison
OISE OI Staff Exempt
OISNE OI Staff Non- Exempt
OIC OI Consumer
Incident Location
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Other- DVR Location or DPS Customer Location
Opportunities Plant 5 - SNAP
Opportunities Plant 5 Life Academy
Opportunities Plant 5 - Transportation
Opportunities - Plant 5 - Production
OI IE, Opportunities – Plant I East
OI IW, Opportunities – Plant I West (Piece Work)
OI IADS, Opportunities – Plant I Adult Day Services
OI IBR, Opportunities – Plant I Break Room
OI IOUT, Opportunities – Plant I Outside
OI IHALL, Opportunities – Plant I Hallway
OI IMR, Opportunities – Plant I Men’s Restroom
OI IWR, Opportunities – Plant I Women’s Restroom
OI I NWH, Opportunities – Plant I North Warehouse
OI I SWH, Opportunities – Plant I South Warehouse
OI ILOAD, Opportunities – Plant I Loading Dock
OI I MAINT, Opportunities – Plant I Maintenance Shop
OI IJANIT, Opportunities – Plant I Janitorial Closet
OI PRINTS, Opportunities – Print Shop
OI ILOBBY, Opportunities – Front Lobby
OI ISJTR, Opportunities – Plant I Spence Jensen Training Room
OI ICONFR, Opportunities – Plant I Conference Room
OI IOFF, Opportunities – Plant I Office
OI IEVAL, Opportunities – Plant I Evaluation Room
OI WARE, Warehouse (Old STC Building)
OI IIL1, Opportunities – Plant II Line 1
OI IIL2, Opportunities – Plant II Line 2
OI IIL3, Opportunities – Plant II Line 3
OI IIL4, Opportunities – Plant II Line 4
OI IIL5, Opportunities – Plant II Line 5
OPI IIDS, Opportunities – Plant II Displays
OI IIMR, Opportunities – Plant II Men’s Restroom
OI IIWR, Opportunities – Plant II Women’s Restroom
OI IIBR, Opportunities – Plant II Break Room
OI IIPROOFF, Opportunities – Plant II Production Office
OI IICONF, Opportunities – Plant II Conference Room
OI IIOUT, Opportunities – Plant II Outside
OI IILOAD, Opportunities – Plant II Loading Dock
OI IIENT, Opportunities – Plant II Entrance
OI IIUPSOFF, Opportunities – Plant II Upstairs Office
OI IIUPSMR, Opportunities – Plant II Upstairs Men’s Restroom
OI IIUPSWR, Opportunities – Plant II Upstairs Women’s Restroom
OI IIUPSCONF, Opportunities – Plant II Upstairs Conference Room
OI IINSW, Opportunities – Plant II North Stairwell
OI IISSW, Opportunities – Plant II South Stairwell
OI IIWH, Opportunities – Plant II Warehouse
OI IIWHOFF, Opportunities – Plant II Warehouse Office
OI II IRC,
OI IILIDS, Opportunities – Plant II Lid Area
OI IIIPROD, Opportunities – Plant III Production
OI IIIOUT, Opportunities – Plant III Outside
OI IIIMR, Opportunities – Plant III Men’s Restroom
OI IIIWR, Opportunities – Plant III Women’s Restroom
OI IIIYAPCR, Opportunities – Plant III YAP Classroom
OI IIIOFF, Opportunities – Plant III Office
OI IIIMEZ, Opportunities – Plant III Mezzanine
OI IIICONF, Opportunities – Plant III Conference Room
OI IIILOAD, Opportunities – Plant III Loading Dock
OI IVOFF, Opportunities – Plant IV Office
OI IV BR, Opportunities – Plant IV Break Room
OI IVMR, Opportunities – Plant IV Men’s Restroom
OI IVWR, Opportunities – Plant IV Women’s Restroom
OI IVYAPCR, Opportunities – Plant IV YAP Classroom
OI IVCONF, Opportunities – Plant IV Conference Room
OI IVENT, Opportunities – Plant IV Entrance
OI IVJANIT, Opportunities – Plant IV Janitorial Room
OI IVMAINT, Opportunities – Plant IV Maintenance Shop
OI IVWH, Opportunities – Plant IV Warehouse
OI IVPROD, Opportunities – Plant IV Production
OI IVLOAD, Opportunities – Plant IV Loading Dock
OI IVOUT, Opportunities – Plant IV Outside
OI IVWH2, Opportunities – Plant IV Warehouse 2
OI COH, Opportunities Consumer Out-of-House (i.e. Piggly Wiggly)
STC- STC Enclave
W&A-W&A Enclave
COM- City of Madison
I-94- I-94 Rest Area
Location Address
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Date of Incident
*
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Day of Week
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Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Time
*
Time
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Time of day
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a.m.
p.m.
Nature of Incident
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No Apparent Injury
Sprain/Strain
Dislocation
Respiratory Emergency
Laceration
Rash
Head Injury
Dental Injury
Burn
Back Injury
Abrasion/Contusion
Eye Injury
Fracture
Bloodborne Pathogen
Other
If Other where?
*
Injured Body Part
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Side
Area
Pick one of each.
Left
Right
Abdomen
Ankle
Arm
Shoulder
Upper Back
Lower Back
Chest
Eye
Face
Foot
Hand
Head
Knee
Upper Leg
Lower Leg
Neck
Teeth
Wrist
Elbow
Caused by
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Another Person
Bite
Bodily Motion
Chemical
Foreign Body
Heat/Thermo
Lifting
Material Handling
Sharp Instrument
Slip/Trip/Fall
Struck by Equipment
Other
If Other what?
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Explanation of Incident or Injury
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Please upload pictures of the incident area and any machinery or equipment involved.
Was blood or other bodily fluid present?
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Yes
No
If yes, was personal protective equipment used?
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Yes
No
Name
Phone
Witness 1
Name
Phone
Witness 2
Name
Phone
Witness 3
Name
Phone
First Aid
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Observation/Rest
Ice/Elevation of injured part
Wound care
Other
Medical Care Needed
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None, Returned to Work
Sent Home
Doctor Urgent Care
Emergency Room
911 called
Other
If Other what?
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If Other what?
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Injured Area
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🛈
Head
Eye
Shoulder
Arm
Elbow
Wrist
Hand
Finger
Back
Chest
Abdomen
Pelvis
Hip
Leg
Knee
Ankle
Foot
Toe
Other
Type of Injury
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Abrasion
Amputation
Bruise
Burn
Concussion
Cut/Laceration
Foreign Body
Fracture
Hearing Impaired
Infection
Pain
Puncture
Rash/Dermatitis
Respiratory
Strain/Sprain
Other
Specify Side
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Left
Right
Specify
*
Was this incident caused by an unsafe act or condition?
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Yes
No
Unsafe Act/Condition
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🛈
Housekeeping
Hazards Not Recognized
Physical/Environmental Stresses
Facility/Design
Materials/Tools/Process
Safeguarding Devices
Exceeding Speed Limits
Work Practices
Protective Equipment
Equipment/Machinery
Other
If yes, please explain:
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Could this injury have been prevented?
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Yes
No
Have similar incidents occurred before?
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Yes
No
If yes, please explain:
*
If yes, please explain:
*
Contributing Factors
*
Conflicting Goals/Policies
Failure to Plan/Anticipate
Responsibilities Not Defined
Lack of Procedures
Resources Lacking
Failure to Act/Correct
Inadequate Time
Failure to Follow Procedure
Knowledge/Skills Lacking
Excessive Physical Demands
Maintenance/Inspection/Repairs
Failure to Use Appropriate PPE
Inadequate Construction/Layout
Inadequate Instructions
Inadequate Designs/Safeguarding
Inadequate Staff
Horseplay
Other
Action(s) to be taken to prevent recurrence
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Additional Comments
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