Injury Analysis Worksheet : Our Services : League Association of Risk Management

This Injury Analysis Worksheet should be completed during a meeting of the injured employee and a supervisor. Please complete the form thoroughly, including as much detail as possible. The worksheet aims to generate and document a discussion between the supervisor and employee regarding the hazard that caused the injury and identify appropriate safety measures needed to avoid future accidents/injuries.

Once completed, hit the submit button at the bottom of the form, which will generate an email to be sent to LARM's Loss Control team to aid them in understanding the incident, recognizing loss trends among all LARM members, and providing resources and/or information for our members to mitigate future accidents and injuries. The completed Injury Analysis Worksheet will be included in the employee's workers' compensation file. The Injury Analysis Worksheet should be reviewed by your Safety Committee as required by the Nebraska Department of Labor.

Thank you for your cooperation in completing the Injury Analysis Worksheet.

Please enter today's date (Required)

Employee information

Employee name

First Name *

Middle

Last Name *

City or Village (Required)

Department

Title

Employee phone (Required)

Length of employment (Required)

Supervisor Information

Supervisor name

First Name *

Last Name *

Supervisor title

Supervisor phone

Accident description

Type of injury and body parts injured (Required)

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Date of injury (Required)

Time of injury (Required)

Date reported (Required)

Exact location of accident (Required)

Describe job being done (i.e. loading truck) (Required)

What occurred? Please include the employee's description of exactly what happened to cause this injury.

What occurred? (Required)

Additional notes from supervisor concerning accident:

Analysis of accident causes

What did the employee do or not do to contribute to the injury? (e.g. failure to use restraint system, inattention, lack of use of PPE)

What did the employee do or not do to contribute to the injury?

Were there any unsafe conditions caused by tools, equipment, or the job site that caused or contributed to the injury? If so, please describe below.

Corrective action plan to prevent recurrence

What changes have been put in place to prevent future injuries of this nature? (e.g. retraining, repair/replace defective equipment, require PPE, improve worksite procedures, define safe method, perform ergonomics)

Correction action (Required)

Additional information completed by supervisor:

Do you have any reason to doubt the validity of this claim?

If yes, please explain.

Has the injured employee had any recent problems with attendance or performance of his or her job?

If yes, please explain.

Are you aware of any other prior injuries or personal conditions the injured employee may have that impacts this claim?

If yes, please explain.

Please list any witnesses to the incident that caused the injury:

Witness name

First Name

Last Name

Witness phone number

Witness 2 name

First Name

Last Name

Witness 2 phone number

Other comments or pertinent information

Injury Analysis Worksheet

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