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SUPERVISOR'S INCIDENT <br />ANALYSIS REPORT <br />MS REPORTING OFFICE NAME OF PERSON <br />WORK LOCATION DATE OF INJURY/ILNESS <br />SUPERVISOR'S NAME TIME OF OCCURRENCE <br />TYPE OF PERSONAL <br />INCIDENT <br />0 NEAR MISS • ILLNESS <br />FIRST AID • DEATH <br />INJURY INCIDENT CAUSE(S) Task performed at time of incident (Check those applicable.) <br />Operating machinery <br />Operating hand tools <br />Operating power tools <br />Material handling <br />Maintenance & repair <br />Motor vehicle driver, passenger <br />Environmental sampling <br />Construction activities <br />Office, clerical work <br />Unknown <br />Ca (Check those applicable.) <br />Improper work procedures <br />Taking unsafe position <br />Violation of safety practices <br />Not using safety equipment <br />Defective equipment/tools <br />Operation without authority <br />Performing unsafe act <br />Others (Describe below.) <br />DESCRIBE THE CONDITIONS ACTS, AND PRACTICES THAT CAUSED OR CONTRIBUTED TO THIS INCIDENT. <br />(Use additional sheets as required Include photographs, maps, and drawings if they are available.) <br />Name and condition of equipment, material, or tools that caused or <br />contributed to the incident. <br />What safety equipment was employee using or wearing? <br />DESCRIBE WHAT SPEC WIC ACTIONS HAVE BEEN TAKEN OR RECOMMENDED TO PREVENT OR MINIMIZE A RECURRENCE <br />OF THE CONDMONS, ACTS, AND PRACTICES THAT CAUSED OR CONTRIBUTED TO THIS INCIDENT. <br />NAME OF PERSON COMPLETING THE REPORT SIGNATURFJDATE