Fire or Explosion
Material or Business Loss
Motor Vehicle Accident
Did an Injury occur?
Nature of Injury
Body Part Affected
Was follow-up treatment required?
Was there a person(s) directly involved?
Worker Contact Number
Worker Experience (Years) in position:
Clearly describe how the incident occurred.
Were there pictures taken?
Were there any witness's to the event?
Witness Name, Contact Info. Attach signed witness statement
Immediate causes, what acts failure to act, and conditions contributed directly to this accident?
Basic causes, what are the contributing factors? (Job factors, personal factors)
What action or recommendations are made to prevent recurrence? When? And action by?