San Francisco International Airport
SUPERVISOR'S INCIDENT INVESTIGATION REPORT
NAME OF INVOLVED EMPLOYEE / CIVIL SERVICE CLASS TITLE & NUMBER
DATE & TIME OF INCIDENT / LOCATION OF INCIDENT / DATE EMPLOYEE REPORTED INCIDENT
AIRPORT DIVISION (check one)
Administration & Policy Operations and Security Business & Finance
Museums Design & Construction Directors/COO Office
Planning & Environ. Affairs Marketing & Communications Facilities ITT / Section/Shop
SEVERITY OF INCIDENT / INJURED BODY PART(S)
First Aid (No medical treatment)
Medical Treatment Injury/Illness
Lost Time Injury/Illness
Property Damage: Type ______
Vehicle Incident
Near Miss, Significant Incident: Type ______
DESCRIPTION OF THE INCIDENT
Once you have thoroughly investigated the facts of this incident, provide a detailed description of the events and circumstances that led to and caused the incident. Attach additional sheets if necessary.
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List any relevant safety and health equipment that the employee was using at the time of the incident (i.e., safety glasses, hard hat, safety vest, gloves, seat belt, hearing protection, respirator, safety shoes, fall protection equipment, flares lockout/tagout devices, traffic control items)
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JSP CSP
Does a Job Safe Practice (JSP) or Code of Safe Practice (CSP) exist for this job? Yes No Yes No
If “No”, will you create a JSP/CSP for this job? Yes No Yes No
If “Yes”, is a revision of the JSP/CSP needed? Yes No Yes No
Please forward any new or revised JSP/CSP to Safety, Health and Wellness Office.
EMPLOYEE INPUT
What suggestions did the employee have for preventing similar incidents?
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CAUSAL FACTORS ANALYSIS
Describe the unsafe act(s), if any. What was done unsafely? / Describe the unsafe condition(s), if any. What was unsafe?
If an unsafe act was committed, describe why the unsafe act(s) was committed. / If an unsafe condition existed, describe why the unsafe condition(s) existed.
CORRECTIVE ACTIONS
What specific actions will be taken to ensure that a similar injury/illness does not occur again? The corrective actions should be aimed at all employees with a similar exposure to the hazard that caused the injury/illness.
IMMEDIATE/TEMPORARY CONTROL ACTION(S) TAKEN / Date Scheduled / Date Completed
PERMANENT OR LONG-RANGE CONTROL ACTION(S) TAKEN / Date Scheduled / Date Completed
ADDITIONAL COMMENTS
List names and addresses of witnesses if applicable
PREPARED BY (PRINT NAME) / DATE / CIVIL SERVICE CLASS AND TITLE
MANAGEMENT REVIEW BY (SIGN NAME) / DATE / COPY SENT TO:
SAFETY, HEALTH AND WELLNESS OFFICE
OTHER: ______
TO BE COMPLETED BY SAFETY, HEALTH AND WELLNESS STAFF
REVIEWED BY / RETURNED TO SUPERVISOR
YES NO / EXECUTIVE STAFF NOTIFIED
YES NO
X:\Safety and Health\Workers' Comp\Forms Revised-May 2014