Appendix C — Supervisor's Report of Injury or Illness

Safety Manual · 2026 Edition · Rev 2.0 · Effective August 2026 · Owner DF

Supervisor's Report of Injury or Illness

3F Construction LLC • 202 N. Justine Street, Chicago, IL 60607 • (312) 296-4855

Type of injury: ☐ Disabling ☐ Medical ☐ Illness ☐ First aid only ☐ Near miss

Name of employee ________________________________ Occupation ____________________

Project / place of incident ______________________________ Date and time __________________

Years of experience ________________ Witnesses ________________________________

Care provided: ☐ Sent to doctor ☐ Given first aid ☐ Refused care ☐ Emergency (911)

1. What was the employee doing when injured?

______________________________________________________________________________________

2. How did the incident occur? (describe fully)

______________________________________________________________________________________

3. Part of body affected / nature of injury:

______________________________________________________________________________________

4. Object or substance that directly injured the employee:

______________________________________________________________________________________

5. Root causes — why was the unsafe act committed? Why did the unsafe condition exist?

______________________________________________________________________________________

6. Corrective actions to prevent recurrence (what, who, by when):

______________________________________________________________________________________

Supervisor signature __________________________________ Date ________________

Safety Coordinator follow-up / closure ______________________________ Date ________________

Reminder: fatalities must be reported to OSHA within 8 hours; in-patient hospitalizations, amputations, or loss of an eye within 24 hours (1-800-321-6742). Determine OSHA 300 recordability within 7 days.