If a blank does not pertain to your incident,accident, injury or illness, type "N/A" in the blank.

  • Name:

  • Address/Phone#:

  • Date of Birth:

  • Job Title:

  • Date Hired:

  • Supervisor:

  • Incident Date/Time:

  • Location:

  • Task Performed:

  • # of Hours Worked

  • # of Hours Awake

  • # of Hours Slept

  • Witness:

  • Immediate Supervisor:

  • Safety Equipment Used

  • Medical Treatment Requested

  • Severity of Incident

  • Was First Aid Given?

  • If Yes....

  • First Aider Qualification:

  • First Aider Address & Phone#:

  • Detailed Description of Incident:

  • What Caused Incident?

  • Employee Recommendation for Incident Prevention:

  • Signature of Employee/Date:

  • Signature of Witness/Date:

Supervisor's investigation Report

  • Supervisor Completing Report's Name:

  • Injury Details

  • Location:

  • Task Performed:

  • Witness:

  • Injured Party:

  • Property Damaged:

  • Injury:

  • Body Part Affected:

  • Outcome:

  • # Of Lost Days

  • # Of Restricted Days

  • HSE Severity:

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