Supervisor / Safety Investigation Report

If you have any questions, please call 801-399-8624, Fax 801-399-8307. Looking for the Employee Report of Incident / Injury

Report Information* is required

*Please describe the incident, giving full details include: Where? What? When? How? Why?

Cause: (check all contributing factors if applicable)

Please Explain

Supervisor Signature

(Optional) Email Copy: