SUPERVISOR’S INVESTIGATION REPORT
Of Employee Job Injury or Illness
Teleclaim 1-877-MDC-RISK (1-877-632-7475)
Is Employee __Permanent __Probationary __Other __________________ Teleclaim # ______________________________________
1. Employee Name __________________________________________________Title __________________________ID #_______________
2. Dept. # _______ Div # ________ Location # ___________ 3. Date of Incident _____________________ Time ___________ AM or PM
Address & Location of Incident __________________________________________________________ City ______________ Zip________
4. Immediate Supervisor ___________________________________________ Phone(s) ___________________________________________
5. Who was this occurrence first reported to? Date ___________ Name _________________________________________________________
Title __________________________ Date ___________ Time _______AM/PM Phone(s) ____________________________________
6. Was this a chemical or biological exposure? ___ Yes ___ No If yes, complete Exposure Report form
7. Was this first reported as a minor injury on the Minor Injury Log? ___ Yes ___ No Date ________________ Time ________ AM or PM
8. Did employee go to: ___ Clinic ___ Doctor ___ Hospital Name of Clinic, Doctor or Hospital ___________________________________
Address _____________________________________________________________ Date _____________ Time ____________ AM or PM
9. Did injured employee do something to cause or contribute to the incident? ___No ___Yes If yes, check item below:
___ Improper planning ___Departure from standard procedure ___ Reckless Behavior
___ Lack of proper skills ___Chose to use defective or improper equipment ___ Inattention ___Other
Describe the above_______________________________________________________________________________________________
10. Did another factor contribute to the accident/injury or illness? ___No ___ Yes If yes, check item below:
___Action(s) of another person ___Departure from standard procedure ___Inadequate / improper training or skill
___Improper planning ___Defective or improper equipment ___Inattention
___Insect/Animal ___Chemical / Biological exposure ___Weather ___Other
Describe the above_________________________________________________________________________________________________
11. What have you and/or your department done to help prevent a re-occurrence? Be specific _______________________________________
________________________________________________________________________________________________________________
12. Names of witness (If witness statements are taken, attach to this report.)
Witness Name __________________________________________________ Title ______________________ Emp. ID______________
Phone(s) _____________________________________________Address____________________________________________________
Witness Name __________________________________________________ Title _______________________ Emp. ID_____________
Phone(s) _____________________________________________Address____________________________________________________
13. Attach supporting documents to this report such as photos, diagrams or other documents. Total number of pages attached ___________
Employee’s Description of Incident (Use attachment if necessary. Number of pages of employee attachment _______)
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
Employee Signature (if available) ________________________________________________________________ Date: _______________
Failure to complete this report accurately is a violation of Miami-Dade County Policies and Procedures. Violations may result in disciplinary action.
Submit to: ISD Risk Management Phone 305-375-4280, Fax 305-375-5492; 111 N.W. 1 Street, 23
rd
Floor / Department retains copy.
Miami-Dade Office of Safety, Risk Management, ISD For the use of the County Attorney’s Office and ISD
http://safetyweb.miamidade.gov/safetyweb/ Rev. Sept. 2012
Instructions for Conducting the Supervisor’s Investigation
If the employee requires emergency medical attention, call 911 or go to the nearest emergency room.
If the employee requires non-emergency medical attention, go a Miami-Dade Authorized Care Center
http://www.miamidade.gov/internalservices/contact-isd.asp .
In accordance with the Miami-Dade County Safety Manual, every employee injury/ illness will be
investigated by the employee’s supervisor as soon as possible after the occurrence.
All employee injuries or illnesses must be reported to Teleclaim 1-877-MDC-RISK (1-877-632-7475) or on
the Minor Injury Log (available from http://safetyweb.miamidade.gov/safetyweb/).
For assistance contact your Departmental Safety Specialist / Representative or the Office of Safety at
305-876-8000.
1. Check the Scene
a. Carefully examine the site of the incident.
b. Reconstruct, as much as possible, the chain of events leading up to the incident, and attempt to
determine what caused the incident.
2. Collect the Evidence
a. Inspect machinery, protective equipment, site conditions, etc., to determine cause and/or contributing
factors to the incident.
b. If equipment or machine parts were defective, remove them from use and contact your Departmental
Safety Specialist/Representative or the Miami-Dade Office of Safety (305-876-8000) for instructions.
Do not return defective/damaged equipment to service.
3. Interview the Employee
a. Ask the employee to start from the beginning and describe what happened.
b. Determine what procedures were (or were not) followed, what equipment was used, etc.
c. If the employee exhibits unusual or erratic behavior, contact your Division Director or DPR
immediately for instructions.
d. Enter the employee’s description of the accident in the appropriate section of the Supervisor’s
Investigation Report and obtain the employee’s signature.
4. Interview Witnesses
a. Interview witnesses at the scene. (Whenever possible, interview witnesses separately.)
b. Obtain their names, titles, addresses, phone numbers and statements.
5. Write It Down, Take Photos, Make Sketch / Diagram
a. Utilize the Supervisor's Investigation Report form to document all facts that relate to the
injury/illness. If necessary, use additional paper to provide further detailed information.
b. Note any unsafe conditions, faulty equipment, procedures not followed, misuse of equipment or
other items which could have caused or contributed to the incident (e.g., lightning, weather,
supplemental evidence, distractions).
c. Attach (and number) all photos, diagrams, statements and any other pertinent information to the
Supervisor’s Investigation Report form.
6. Review the Supervisor’s Investigation Report
a. Review the evidence. Ensure that complete and adequate information is presented. If necessary,
conduct further questioning of employee or witnesses.
b. Within 48 hours of the incident, forward the Supervisor's Investigation Report and any additional
information to: ISD Risk Management, Suite 2340, 111 NW 1 Street; Phone: 305-375-4280 / Fax:
305-375-5492. Retain a copy for your department.
ACCIDENT OR INCIDENT NOTIFICATION All employee injuries or illnesses must be reported to Teleclaim
1-877-MDC-RISK (1-877-632-7475) or on the Minor Injury Log (http://safetyweb.miamidade.gov/safetyweb/).
If the incident results in death or serious injury, promptly call the Miami-Dade Office of Safety at 305-876-8000 or
after hours at 305-546-1419 and ISD Risk Management at 305-375-4280.
ISD RISK MANAGEMENT INVESTIGATION All County personnel shall cooperate fully with ISD Risk
Management staff conducting accident or incident investigations. ISD Risk Management investigations may be
conducted in addition to, and independent of, departmental investigations.
Miami-Dade Office of Safety, Risk Management, ISD http://safetyweb.miamidade.gov/safetyweb/ Phone 305-876-8000
