• Location

  • Job #:

  • Date of occurrence

  • Date reported

  • This incident involved:

  • Please choose all that apply.

Type of Incident. Select all that apply.

  • Type of incident. May be multiple types.


  • Were there any injuries?

  • Type of injury?
  • Add media

Person(s) Directly Involved With The Incident.

  • Were there people involved in the incident?

  • Please enter the names of those involved.
  • Employee name

  • Date of Birth

  • Address


  • Were there any witnesses to the incident?

  • Please enter the names of those involved.
  • Employee name

  • Date of Birth

  • Address


  • Clearly describe how the incident occurred.

  • Add media

  • Add drawing


  • 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?

Frequency Potential

  • The Frequency Potential is:


  • The Severity Potential is:


  • Estimated:

  • Actual:


  • Extra comments

  • Extra Media

  • Investigated by:

  • Investigated by:

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