SUPERVISOR’S INVESTIGATION REPORT
OF EMPLOYEE ON-THE-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 #:______ Date of Incident:___________________ Time: __________ AM PM
3. Address and location of incident:_______________________________________________ City:____________________ Zip:_________
4. Employee's Description of Incident (Use attachment if necessary. Number of pages of employee attachment _____)
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
Employee Signature (if available):___________________________________________________________________ Date:_________________
5. Who was the incident first reported to? (print): ____________________________ (signature):_______________________________________
Date:________ Time: ________ am pm Phone(s):________________________________________________________________
6. Was this first reported as a minor injury on the Minor Injury Log? Yes No Date:______________ Time: __________ AM PM
7. Who completed the Minor Injury Log? Name:______________________________ Title: ________________________________________
8. Did employee go to: clinic doctor hospital? If known, Name of clinic, doctor or hospital: _________________________________
9. Was this a chemical or biological exposure? Yes No If yes, complete Exposure Report form.
10. Did injured employee do something to cause or contribute to the incident? Yes No If yes, check reason item below:
Improper planning Departure from standard procedure
Inattention
Reckless Behavior
Lack of proper skills
Chose to use defective or improper equipment
Failed to follow instructions
Other
11.
Did another factor contribute to the accident
/injury or illness
?
Yes No If yes, check reason 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
12. What have you and/or your department done to help prevent a re-ocurrence? Be specific (attach additional information if applicable):
____________________________________________________________________________________________________________
13. Witness Name: ____________________________________ Title: _________________________ Phone:__________________________
Witness Name: ____________________________________ Title: _________________________ Phone:__________________________
14.
Attach supporting documents to this report such as photos, diagrams, witness statements or other documents. Total number of pages attached____
15. Supervisor (print):___________________________________(signature):___________________________Phone:__________
__________
Failure to complete this report accurately is a violation of Miami-Dade County Policies and Procedures. Violations may result in disciplinary action.
Submit completed report to: ISD Risk Management, Worker's Compensation, Phone: 305-375-4280 and a copy to
Office of Safety, Phone 305-876-8000, 111 N.W. 1st St., 23rd Floor / Department retains copy.
160_05-11B 9/18
_________________________________
_________________________________
Employee Injuries
• If the employee requires emergency medical attention, call 911 or proceed to the nearest emergency room.
• If the employee requires non-emergency medical attention, the employee should be seen at a Miami-Dade Authorized Care Center
http://intra.miamidade.gov/internalservices/workers-compensation.asp (or call 305-375-4280).
• All employee injuries or illnesses must be promptly reported to Teleclaim 1-877-MDC-RISK/877-632-7475 or, if there is no medical attention or
lost time, on the Minor Injury Log (available from Safety website).
• If the incident results in death, serious injury, or serious damage, promptly notify the Miami-Dade Office of Safety at 305-876-8000 (after hours
305-546-1419) and ISD Risk Management at 305-375-4281.
The Supervisor’s Investigation Report In accordance with the Miami-Dade County Safety Manual, every employee injury will be investigated by the
employee’s supervisor as soon as possible after the occurrence, and reported on the Supervisor’s Investigation Report. For assistance contact the
Departmental Safety Representative or the Office of Safety (305-876-8000).
How to Conduct an Accident Investigation
1. Check the Scene
a. Carefully examine the site of the incident, equipment and conditions.
b. Reconstruct, when possible, the chain of events leading to the incident, and determine what caused the incident.
2. Collect the Evidence
a. Inspect machinery, protective equipment, site conditions, etc., to determine cause or contributing factors.
b. If equipment or machine parts were defective, remove them from use, tag and disable damaged or defective equipment, and contact your
Departmental Safety Representative or the Miami-Dade Office of Safety (305-876-8000) for instructions. Do not return defective or 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 employee exhibits unusual or erratic behavior, contact your Division Director or DPR immediately for instructions.
d. Provide the employee’s description of the accident in the appropriate section of the Supervisor’s Investigation Report.
4. Interview Witnesses
a. Interview witnesses at the scene. (Whenever possible, interview witnesses separately.)
b. Obtain witness name, address, phone number and statement. Attach additional paper if necessary.
5. Write It Down, Take Photos, Make Sketch / Diagram
a. Utilize the Supervisor's Investigation Report form to document all information. Attach additional paper if necessary.
b. Describe unsafe conditions, faulty equipment, procedures not followed, improper use of equipment, weather or other items which could have
caused or contributed to the incident.
c. Attach (and number) photos, diagrams, statements and other pertinent information to the Supervisor’s Investigation Report.
6. Review and Submit the Supervisor’s Investigation Report
a. Review the information. Is it complete and adequate? 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. Submit copies to your Departmental Safety Representative and
in accordance with your department’s protocol.
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 or
other investigations.
Miami-Dade Office of Safety, Risk Management, ISD Phone 305-876-8000
Safety Website: http://intra.miamidade.gov/internalservices/safety-web.asp
Rev. September, 2018
"SUPERVISOR'S INVESTIGATION REPORT" INSTRUCTIONS
