Supervisor's Incident Investigation Report
Suwannee County
Date:
Employee Name:
Address:
City:
State:
ZIP:
Social Security #:
DOB:
Phone #:
Job Title:
Hire Date:
Wage Rate:
Department:
Supervisor's Name:
Place of Incident:
Date of Incident:
Time of Incident:
Date Incident Reported:
Witness (1) Name:
Phone #:
Witness (2) Name:
Phone #:
Who was Notified?:
Description of Incident:
Describe damage to equipment or property:
As you reviewed the facts, what caused this Incident?:
What action has been or will be taken to prevent recurrence?:
Other Persons Involved:
Signature of Reporting Employee:
Date:
Supervisor Signature:
Date:
Your Name:
Your E-Mail*:
*must be valid e-mail address!