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FROI First Report of Incident
First Report of Incident Spanish
Supervisor/Safety Report

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Safety Report (SROI)

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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

Please select an option.

Do you usually supervise this individual?

Yes

If no, explain:

Please select an option.

Was accident immediately reported?

Yes

If no, explain:

Please select an option.

Did you physically inspect the area where the injury occurred?

Yes

If no, explain:

Please select an option.

Any unsafe conditions or unusual hazards present?

Yes

If yes, explain:

Please select an option.

Was employee wearing back support?

Yes

If no, explain:

Please select an option.

Evidence of horseplay?

Yes

If yes, explain:

Please select an option.

Evidence of intoxication?

Yes

If yes, explain:

Please select an option.

Evidence of drug abuse?

Yes

If yes, explain:

Please select an option.

Are you satisfied that the accident/injury occurred as reported?

Yes

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

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

Safety Report (SROI)

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