City of Des Moines, WA

Supervisor's Name

Title

Was the employee engaged in the regular course of employment when the incident or saefty condition occurred?
 Yes
 No

Was the employee directed to a doctor?
 Yes
 No

Was the employee directed to a hospital?
 Yes
 No

Injury to:

Head	Arm	Face	Glasses/Contact
Hand	Leg	Eye	Other:
Foot	Back	Teeth

Injury type:

Wound	Bruise	Spriain/Strain	Disease/Infection
Hernia	Burn	Fracture	Previous injury aggravated
			Other:

Contributing casue(s), if any?

Operating without Authority	Operating at unsafe speed
Taking unsafe position	Making saefty devices inoperative
Distraction, horseplay	Using unsafe loading/mixing procedures
Failure to use protective devices	Working on moving/dangerous equipment
Using unsafe equipment	Using equipment unsafely

Descrition of incident or safety condition:

What could have been done to prevent this type of incident?

Has the employee  been consuled on a similar behavior related to this incident?
 Yes
 No

Date of last incident: 

Supervisor's Signature: 

Date:

Safety Representative's Signature: 

Date: