Supervisor's Statement Logo
  • Supervisor Statement

    To be used following a work related accident/incident
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  • Supervisor's Evaluation of Accident/Incident

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  • Root Causes and Analysis

  • Preventive Action Plan

  • Instructions

    List the root cause(s), or reason(s) why the incident occurred (identified from Analysis).  For each root cause, identify a preventive action (things that supervisor or employee will do to prevent the incident from occurring again).

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    Supervisor Certification - By clicking Submit the supervisor (or designee) certifies that the information provided is true and correct to the best of the supervisor's (or designee's) knowledge

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