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FROI First Report of Incident
First Report of Incident Spanish
Supervisor/Safety Report
Supervisor/Safety Report
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Safety Report (SROI)
Submit Safety Report
EMPLOYER
Employer (no comma or non alpha characters)
Please provide a valid employer name.
Employee (no comma or non alpha characters)
Please provide a valid employee name.
Date of Loss
Please provide the date of loss.
Was Employee Working Alone?
Yes
No
Please select an option.
Do you usually supervise this individual?
Yes
No
If no, explain:
Please select an option.
Was accident immediately reported?
Yes
No
If no, explain:
Please select an option.
Did you physically inspect the area where the injury occurred?
Yes
No
If no, explain:
Please select an option.
Any unsafe conditions or unusual hazards present?
Yes
No
If yes, explain:
Please select an option.
Was employee wearing back support?
Yes
No
If no, explain:
Please select an option.
Evidence of horseplay?
Yes
No
If yes, explain:
Please select an option.
Evidence of intoxication?
Yes
No
If yes, explain:
Please select an option.
Evidence of drug abuse?
Yes
No
If yes, explain:
Please select an option.
Are you satisfied that the accident/injury occurred as reported?
Yes
No
If no, explain:
Please select an option.
What additional training may have prevented this accident?
What additional training would you like the Fund's Safety Director to provide?
What circumstances contributed to this accident?
What changes in circumstances or actions could have prevented this accident?
Your actions taken to minimize the chance of a reoccurrence?
Your future plans to minimize the chance of a reoccurrence.
Would you like to speak to any Fund Professional?
Yes
No
If yes, please list:
Please select an option.
Supervisor
Supervisor's Name
Please provide supervisor's name.
Preparer's Email (form will be sent to)
Please provide a valid email address.
Supervisor's Phone
Supervisor's Fax
Admin Only:
Submit Safety Report.