Transcription of SUPERVISOR’S ACCIDENT/INCIDENT INVESTIGATION REPORT
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SUPERVISOR’S ACCIDENT/INCIDENT INVESTIGATION REPORT
OSP FORM 300 Distribution: Director, WC Administrator, Safety & Health Director COMPLETE FOLLOWING CHECKLISTS supervisor S ACCIDENT/INCIDENT INVESTIGATION REPORT FILE NO.: DATE: / / Date of accident : / / Time of Day : AM : PM Date Reported: / / accident Occurred On Employer s Premises?: Yes No supervisor s Name: Telephone No.: ( ) - : Address: Division: City: Location of accident (specify site within facility): Witnesses Name: Day Telephone Number: ( ) - Witnesses Name: Day Telephone Number: ( ) - PERSONAL INJURY 1.
OSP FORM 300 Distribution: Director, WC Administrator, Safety & Health Director COMPLETE FOLLOWING CHECKLISTS SUPERVISOR’S ACCIDENT/INCIDENT INVESTIGATION REPORT
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