To whom did you report the injury?
What part of the body was injured? Describe in detail
What was the nature of the injury? Describe in detail
Describe fully how the incident happened?
What were you doing prior to the event?
Was equipment, tools being used?
Explain what equipment, tools were being used?
What caused the event?
What other factors contributed to the injury (weather, lighting, accessibility, condition of property, etc.)?
Were safety regulations in place and used?
What was wrong?
Recommended preventive action to take in the future to prevent reoccurence
Were there any witnesses?
Enter witness name
Employee went to doctor/ clinic?
Clinic Phone Number
Police were called to the scene
Name of the Agency Reported to?
Police reference number
Work Order Number
Customer's Phone Number
This document when complete should be sent by email to: email@example.com and your FSM.