Supervisor Incident Report – PDF fillable form

Supervisor Incident Report – word

Instructions for Supervisors:

• The Supervisor’s Incident Report DOES NOT REPLACE the NJ First Report of Injury.
• The  Supervisor’s Incident Report aims to identify root causes and prevent future occurrences: FACT FINDING, NOT FAULT FINDING.
• An electronic version of the Incident Report (Word / PDF) is available on the JIF website.
• The Supervisor Incident Report may be used to investigate Workers’ Compensation, Property, Automobile, and General Liability Incidents.
• Claims Coordinators should continue to report claims as previously instructed.
• Action Items should be forwarded to a responsible individual to act on the managerial or financial aspects of the stated action item.

When an Accident Occurs:

• Render any necessary medical assistance.
• Take steps to secure the site.
• Notify law enforcement if a motor vehicle is involved.
• Take photos and preserve equipment involved in the accident.
• Use the Incident report form as a guide to identifying ways to prevent future occurrences.
• Prepare the report in sufficient detail so that the basic facts can be documented, corrective action(s) can be identified, and accountability assigned.
• Participate in the Safety Committee or Accident Review discussion of the incident.
• Follow-up and provide feedback on the implementation of action items assigned to you.

Suggested Report Distribution:

Supervisor – Send completed report to Claims Coordinator; Attach Police Report and photos for all Motor Vehicle and property damage reports.

Claims Coordinator – Send completed Supervisor Incident Investigation Report to:

1.  AmeriHealth
2. J.A. Montgomery Risk Control
3. Your Municipal Safety Coordinator