An employee must report any injury that occurs on the job to his/her supervisor as soon as possible. The supervisor’s responsibilities are to:
- Make sure the injured employee receives immediate medical attention and ensure that no one else is at risk for a similar injury
- Report the accident within 8 hours to the Environmental Safety & Health office (x 2401)
- Complete the Supervisor’s Accident/Illness Investigation Form (Form 620).
No matter how safety conscious we are at CSUN, human and system errors will sometimes lead to accidents. Our goal is to find out what caused an accident and prevent it from happening again; an accident investigation helps us meet that objective. Environmental Safety & Health staff members are available to help supervisors investigate the causes of an accident and complete the investigation form.
Supervisor’s Accident/Illness Investigation Form
Here’s a brief, section-by-section overview of the information required by Form 620. All fields on this form must be completed.
I. General Information
This section identifies the injured employee, department and employee status.
II. Accident Data
This section provides a place to specify what the injured employee was doing at the time of the injury and which body parts (e.g., right hand, left lower leg, back of head) were affected. The specific time and location—building, room and/or area—are also noted here.
Sample injury descriptions: foreign body in eye, cut, puncture, bruise, sprain, strain, fracture, burn, dermatitis, etc.
III. Investigation
Supervisors use this section to describe an accident, its cause and any corrective action (already taken or recommended), and to indicate whether they believe the accident industrial in nature.
Description of Accident
- What was the employee doing at the time of the incident?
- What sequence of events led to the incident?
- What were the working conditions and tools being used?
- Any witnesses or contributors to the incident?
- How did the accident happen?
- Accident types include: struck against, struck by an object, caught in or between, slipped, tripped, overexertion, inhaled, absorbed, ingested, contact with electric current.
Cause of Accident
Causes generally include unsafe acts or equipment, as well as poor or improper training. Other possible causes may include:
| Possible Causes | Possible Causes |
| Improper instruction | Unsafe lifting or carrying |
| Lack of skill | Poor ventilation or lighting |
| Operation without authority | Improper guarding |
| Horseplay | Improper maintenance |
| Physical impairment | Improper safety device |
| Failure to warn or secure | Improper tool |
| Failure to lockout | Chemical spill |
| Unsafe position or speed | Lack of time |
| Improper protective equipment | Work overload |
| Poor housekeeping | Failure to inspect |
| Unsafe arrangement | Failure to enforce |
| Hazardous condition | No inspection made |
| Unsafe process or procedure | Failure to train |
Corrective Action (Taken or Recommended)
This section describes the corrective action that the supervisor has taken or will take to prevent similar accidents from occurring in the future. Such action may require involvement from other departments, such as PPM for repairs or EH&S for training.
Industrial Injury Verification
Here the supervisor verifies that the injury occurred while the employee was on the job and covered by Workers’ Compensation. If the supervisor believes that the injury did not happen during the course of employment, an explanation is necessary.
IV. Treatment Data
This section provides space to describe the employee’s medical treatment and whether or not the employee has returned to work.
The supervisor must sign and date the report.
Tips for Supervisors
- Examine the accident site and preserve the scene, if necessary.
- Take photos or make a diagram if it helps explain the situation.
- Remove/repair unsafe conditions.
- Interview witnesses as necessary.
- Be sure your report is legible.
- Use additional pages for the report, if necessary.
Call Environmental Safety & Health at (818) 677-2401 to report serious injuries and/or any that require overnight hospitalization and whenever an employee is transported off campus for medical care.
| REVISION | CHANGES | DATE |
| 1.0 | Reviewed | December 2018 |