Identification of the Incident

  • Type of injury

  • Incident recognized by

  • Date of Incident

  • Date Reported

  • Any witnesses

  • Location of Incident (Department, Machine No., etc)

Description of Incident

  • Give specific details of Incident

Description of Injury and Treatment given

  • Give specific details of Injury

  • Was first aid required

  • Was Medical Attention Required

  • What type of initial treatment received and by whom

The Cause and Remedy

  • What caused the incident

  • Was an unsafe act committed or did unsafe conditions exist. ( explain in detail)

  • Could incident have been prevented. ( explain in detail)

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