Incident Identification Information

  • Type of Injury:

  • Who was involved/Injured in the Incident?

  • Date and Time Incident Occured:

  • Date and Time Incident Was Reported:

  • Were there any witnesses to the incident?

  • If yes, who?

  • Location of Incident (area at the site):

  • Describe the incident in detail:

Injury and Treatment Identification Information

  • Was first aid required?

  • Was emergency medical attention required?

  • Describe the injury in detail:

  • What type on initial treatment was administered, and who administered it?

Cause and Remedy Identification Information

  • Has this or a similar incident occurred at this site before?

  • If yes, with what frequency?

  • Was company policy violated to create this incident?

  • If yes, what policy?

  • Was there an unsafe act or unsafe condition involved in this incident?

  • If yes, explain in detail.

  • In hind sight, could this incident have been avoided?

  • If yes, explain in detail.

  • Describe what can be done to prevent this or similar incidents in the future:

Signatures

  • Who created this report?

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