Team Member- Basic Information

  • (A) Perspective Report #

  • (B) Team Member Name ( Last, First, MI)

  • (C) Incident Date and Time

  • (D) Date Incident Reported

  • Employment Status

  • Regular Job

  • Job Performing

  • Department

  • Date of Hire

  • Date in Current Job

  • Experience with Job Task

  • Length of Shift (in hrs)

  • Shift

  • Shift Start Time

  • Type of Shift

  • Team Member Days Off

Incident Information

  • Incident Type

  • Exact Location of Incident ( if off property, give address)

  • Equipment or Materials Involved

  • Contact Agent (the exact object/material that caused injury)

  • Describe The Incident

  • Provide a Drawing if Helpful

  • Please Add a Photo When Applicable

Incident Type

  • Type of Incident

  • Please Describe

Incident Analysis

  • Environment

  • Please Describe

  • Team Member

  • Mark All That Apply

  • Mark All That Apply

  • Mark All Applicable

  • Equipment

  • Please Describe

  • Management (Must have at least one checked)

  • Please Describe

Preventive Measures

  • What Action Has Been Taken or is Planned to Prevent Recurrence

  • Please Describe

  • How Will The Above Action(s) Improve Operations?

Signature and Review

  • NOTE: I have reviewed this report, I am confident that the incident was thoroughly analyzed and proper actions have been taken or are planned to be taken to prevent recurrence.

  • Analysis By (Immediate Supervisor)

  • Team Member Involved

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