Injured Employee Investigation Report Page 1 of 2

Important: The supervisor should complete this form immediately after the incident.

Organization Name: Branch/Location:

Injured Employee Name: Male Female

Home address: Phone:

Date of hire: / / Job title:

Officer: Yes No International Staff: Yes No Seasonal Staff: Yes No

Full-Time: Yes No Part-Time: Yes No

Date of injury: / / Time of injury: AM PM

Was first aid provided onsite? Yes No Was outside medical attention sought? Yes No

(If applicable) Name of facility or physician that provided treatment:

Supervisor signature: Date: / /

What were you doing just before the incident occurred? Describe the activity and any materials, equipment, or tools being used – be specific. For example: “climbing a ladder while carrying roofing materials” or “entering data into computer”

What happened? Tell how the incident occurred, including where you were. For example: “the ladder to the roof was not secured; it slipped, and I fell” or “I was on the ball field helping a child get up; while lifting the child something in my back snapped”

What was the injury or illness? Explain what body part was affected and how it was affected – be specific. For example: “sprained lower back” or “chemical burn in eyes” or “multiple contusions and abrasions on arms, legs, and shoulder”

Were there witnesses to the incident? Yes No If “Yes”, provide names and phone numbers below

Name: Phone:

Name: Phone:

Name: Phone:

Direct Supervisor’s Accident Investigation Please categorize the incident on page 2 of this report

Accident / exposure description – Identify the immediate cause, any intermediary causes, and root cause of the incident

Preventive action recommendations – If root cause is protocol, defective equipment, or training, suggest correction

Corrective actions taken – If root cause is violation of safety rule, explain corrective action taken

Supervisor: Signature: Date: / /

Director Responsible: Reviewed Executive Director: Reviewed

Please complete page 2 of this form (over)

THE REDWOODS GROUP IEIR 3/14/14

Injured Employee Investigation Report (cont.) Page 2 of 2

Please check one and only one box in each of the following sections:

n SPECIFIC LOCATION OF INCIDENT

Aquatics Area
Athletic / Play Field
Before/After School
Cabin / Tent
Campfire / Meeting Area
Challenge Ropes Course
Child Watch / Babysitting
Childcare Area
Class / Meeting Room
Climbing Wall / Tower
Ex Room: Aerobics, Zumba Etc. / Ex Room: Cardio / Strength Equip
Ex Room: Free Weights
Gym
Gymnastics Area
Kitchen/Food Prep
Lobby / Halls / Front Desk
Locker / Rest Room /Showers
Maintenance / Service Area
Parking Lot / Garage
Play Structure Or Area (Int.) / Playground (Ext.)
Pool
Racquetball / Tennis
(Etc.) Court
Residence Facility
Off Premises / Inside
Off Premises / Outside
On Premise / Outside
Roadway / Streets
Sidewalks / Pathways
(On Premise) / Sidewalks / Pathways
(Off Premise)
Skating Rink / Skate Park
Spa / Sauna / Steam
Stables / Horses
Stairs / Exterior
Stairs / Interior
Waterfront (Non-Pool)
Other

n PROGRAM NAME

Aquatics
Camp: Day / Holiday
Camp: Resident
Camp: Sports
Childcare: Before & After / Childcare: Child Watch
Childcare: Preschool / Daycare
Custodial / Housekeeping
Food Prep
Health & Fitness: Organized / Health & Fitness: Personal
Maintenance / Housekeeping
Office Staff
Senior Program / Activity
Social Outreach (Incl. Residence) / Special Events / Field Trips
Sports: Adult
Sports: Youth
Other

n GENERAL ACTIVITY

Aquatics: Boating, All Forms
Aquatics: All Others
Aquatics: Lifeguard
Aquatics: Operating
Animal: Care
Baseball / Softball / T-Ball
Basketball
Bicycles / Motorbikes/Golf Carts
Class: Aerobics
Class: Kick-Boxing
Class: Martial Arts / Climbing
Dance
Exercise: Cardio Equip.
Exercise: Free Weights
Exercise: Strength Equip.
Exercise: Run / Walk
Exercise: Other Personal
Football
Games / Structured Activity
Gymnastics Demo
Gymnastics Spot / Hiking / Backpacking
Hockey (Ice or Roller)
Horseback Riding
Housekeeping
Landscaping
Lifting / Moving: Child
Lifting / Moving: Objects
Maintenance
No Accident Reported
Office Work
Playground Equipment / Racquetball / Tennis / Squash
Skateboarding
Skating (Ice or Roller)
Skiing / Snowboarding
Skiing / Water
Soccer
Transportation / Driving
Volleyball / Walleyball
Walking (Incidental)
Other

n SPECIFIC ACTION

Aggressive Behavior Of / By
Bending / Kneeling
Caught In, By, or Between
Climbing
Contact With / Exposure To
Cutting / Driving / Riding
Exertion
Fall (From, Onto, Into, or Against)
Horseplay
Inhale / Ingest / Lifting / Moving
No Accident Reported
Participation / Playing
Pushed / Pulled / Bumped
Slip / Swimming
Struck By / Against
Trip
Typing / Keying
Other

n SOURCE OF INJURY

Aquatics Facility: Deck / Dock
Aquatics Facility: Equipment
Aquatics Facility: Sides / Bottom
Aquatics Facility: Body of Water
Aquatics Recreation Equipment
Blood / Body Fluids
Chemicals / Door
Environment: Sun, Heat, Etc.
Equipment: Exercise
Equipment: Housekeeping
Equipment: Office
Equipment: Playground
Equipment: Tools / Floor / Ground
Furniture
Insect / Animal / Poison Ivy
Ladder / Step Stool
Machinery
Object (Ball/Bat/Toy/Nail Etc.) / Person (Another)
Self
Vehicle
Wall / Vertical Surface
Other

n APPARENT INJURY

Abrasion / Scratch
Bite / Sting
Breathing Shortened / Impaired
Bruise / Contusion
Burn / Blister / Chemical Exposure
Dislocation
Dizziness / Unconscious
Fracture / Break
Irritation / Reaction / Rash / Jam
Laceration / Cut
Pain / Soreness
Pinch / Crush
Puncture / Seizure / Dysfunction
Sprain / Strain
Stress / Mind / Psyche
No Visible / Apparent Injury
Other

n BODY PART please check if applicable right left upper lower

Arm
Hand
Wrist
Elbow / Finger Leg
Foot
Ankle / Knee
Toe
Shoulder
Chest / Stomach
Side
Back
Buttocks / Hip
Groin
Face
Ear / Eye
Nose
Head
Neck / Heart
Lungs
Mouth / Lips
Mind / Psyche / Teeth
None / Not Applicable Other

n FOOTWEAR – for Slip, Trip, Fall injuries:

Barefoot
Boot / All Weather Shoe / Closed Toe Flat Shoe (Sneaker or Athletic)
Closed Toe Flat Shoe (Other than Sneaker or Athletic) / Flip Flop / Sandal
Heels / Protective Shoe (Steel Toed Shoe / Boot, etc.)
Other

THE REDWOODS GROUP IEIR 3/14/14