Has someone been hurt?
Name ( First and Last)
Contact phone number for injured person
- PM / SM
- 0-2 hours
- 2-4 hours
- 4-6 hours
- 6-8 hours
- Greater than 8 hours
- Not applicable
- Bruise / Graze
- Strain / Sprain
- Broken bone/s
Does the injured person require medical treatment?
Has anything been damaged?
What has been damaged?
Have Police or Fire services been called?
Where did the incident happen?
Equipment or materials involved:
Describe the incident
Have any actions been taken to prevent this from happening again?
Describe actions taken to prevent this from happening again.
I have reported this incident to the best of my knowledge and any actions that can be taken have been done or are planned to prevent recurrence.
Name of person completing this incident report:
H&S DEPARTMENT USE ONLY
- Training & Coaching
- Training for Leaders
- Development of Training
- Improve Procedure
- Improve Housekeeping
- Job Hazard Analysis Needed
- Guard/Safety Device
- Tools/Equipment Replaced or Repaired
- Eliminate Congestion
- Improve Design/Construction
- Substitute Safer Materials/Supplies/Chemicals
- Improve Illumination
- Improve Ventilation
- Reduction in Noise/Vibration
- Enforce Procedures
How will the above action(s) improve operations?
Who is responsible for ensuring the above is done?
When and how will we monitor the effectiveness of the above preventative measures?
I have reviewed this report, I am confident that the incident was thoroughly analyzed and proper actions have been taken or are planned to be taken to prevent recurrence.
Analysis By Health and Safety Advisor