Lost Time Injury?
Fire or Explosion?
Material or Business Loss
Motor Vehicle Accident
What type of injury?
What body part was injured?
Was follow-up treatment required?
Date of Birth
Clearly describe how the incident occurred.
Include the names and phone numbers of any witnesses to the incident. Attach witness statements.
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?