Supervisor’s Incident Investigation Report

Supervisor's Incident Investigation Report: Gloucester County Insurance Commission

General Information
Confirm Entity*
- County
- College
- GCIA
- GCUA
- GCLC
(Please select your entity)
Department / Division*
Exact Location of Incident (Please include completed address including building /floor /room)*
Date of Incident*
Time of Incident*

: HH

MM
Date Reported to Supervisor*
Temperature
Weather Conditions
Light Conditions

Save and Continue Later

Save and Continue Later

Supervisor’s Description of Accident
Clearly relate events leading to incident.
Supervisor Uploads (attach pictures, diagrams, etc.)
Drop files here or
DO NOT UPLOAD EXHIBIT Z FORM
Why did this incident happen (identify root cause and list all factors that helped to cause the incident?)
What could be done to prevent recurrence?*
Date of most recent training relevant to this incident:
Supervisor Signature*
First Last
(by filling out your name, this will be considered your signature)
Signature Date
Supervisor Email*
Enter Email Confirm Email

Save and Continue Later

Save and Continue Later

Witness #1 Description of Incident as Related to Supervisor
Witness #1 Name
Witness #1 Contact Number
Witness #1 Title
Witness #1 Employer
(if other than entity listed on page 1)
Description of incident:
What actions, conditions, or lack of actions contributed to incident? What could be done to prevent recurrence?
Did you actually see the injury occur?

Save and Continue Later

Witness #2 Description of Incident as Related to Supervisor
Witness #2 Name
Witness #2 Contact Number
Witness #2 Title
Witness #2 Employer
(if other than entity listed on page 1)
Description of incident:
What actions, conditions, or lack of actions contributed to incident? What could be done to prevent recurrence?
Did you actually see the injury occur?

Save and Continue Later

End of Report
Please ensure all information is updated and accurate. If you are completed, please click "submit" below. If you need to make additional edits or revision, click the "previous" buttons and edit the information. If you want to come back later to complete the information, click "save" and follow the instructions.

Save and Continue Later

Gloucester County Insurance Commission