IDC Supervisor Incident Report Form

• Name of employee

• Job Title

• Shift employee working at time of incident

  1st shift

  2nd shift

  3rd shift

• Date and time of incident

  Date

• Date incident reported

  Date

• Day of week incident took place

  Select Monday Tuesday Wednesday Thursday Friday Saturday Sunday

  • Monday
  • Tuesday
  • Wednesday
  • Thursday
  • Friday
  • Saturday
  • Sunday

• Hours worked prior to the incident

• How long has the employee worked for IDC?

  Select 0-3 months 3-6 months 6-12 months 1-3 years 3-5 years 5+ years

  • 0-3 months
  • 3-6 months
  • 6-12 months
  • 1-3 years
  • 3-5 years
  • 5+ years

• Prepared by

• Location
  Address

Incident Details

• Incident Class

  Incident

  Information Only

• Incident Type

  Injury / Illness

  Property

• Date and time of incident

  Date

• Were there any injuries?

  Yes

  No

• Description of injury (include specific body part, as well as extent of injury)

• What was the employee doing right before the incident occurred?

• Type of injury

  Select Fall from height Slip / fall from same level Hazardous material Electric shock Caught between / underneath Falling object Cut / laceration Strain / sprain Struck by equipment / material Contusion Other

  • Fall from height
  • Slip / fall from same level
  • Hazardous material
  • Electric shock
  • Caught between / underneath
  • Falling object
  • Cut / laceration
  • Strain / sprain
  • Struck by equipment / material
  • Contusion
  • Other

• Take photos of area where incident occurred/ other pertinent photos

  Media

• Was Medcor contacted?

  Yes

  No

  N/A

• Did the employee receive first aid / medical care?

  Yes

  No

  N/A

• Where did the employee receive care?

  Emergency Room

  Occupational Clinic

  Personal Physician

  First aid-onsite

• Were there any witnesses

  Yes

  No

  N/A

• Witness name(s)

• Does management need to be contacted? (Always answer yes)(we can change this)

  Yes

  No

• Was there any damage to property or plant?

  Yes

  No

• Description of damage

• Take photo of damage

  Media

• What caused the incident?

• Take photo of surrounding environment including any annotations

  Media

• What actions will be taken to eliminate future repeats of the incident?