Title Page
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Date and Time
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Location
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Prepared by
Company Information
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Which company had incident?
Incident Type
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What Happened?
- Near Miss
- First Aid
- Doctor Assisted
- Vehicle Accident
- Equipment Damage
- Property Damage
- Other
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Describe near miss
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Pictures of issue
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Type of Equipment?
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What was damaged?
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Pictures of damages
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What was damaged?
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Pictures of damages
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Description
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Pictures Taken?
Vehicle Details
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Vehicles
Vehicle
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Vehicle Make
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Vehicle Model
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Year
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Vehicle Tag
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Driver/ Operator
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Photos of IDs and Insurance
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Photos of Equipment/Vehicle
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Please detail any further information regarding this vehicle (if applicable)
Injury Details
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Injuries
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Full Name
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Picture of ID
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Type of injury or illness? (select all that apply)
- Superficial
- Open Wound
- Fatality
- Concussion
- Sprain
- Respiratory
- Eye Injury
- Burns
- Fracture
- Electrocution
- Fall
- Strain
- Dislocation
- Struck by object
- Entanglement
- Assault
- Muscle & Tendon
- Nerve & spinal cord
- Amputation
- Intracranial
- Other Injury
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Describe type of injury or illness
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Parts of body affected? (select all that apply)
- General Ailment
- Head
- Eye (Left)
- Eye (Right)
- Ear
- Nose
- Throat
- Neck
- Back (Upper)
- Back (Lower)
- Arm - Upper (Right)
- Arm - Upper (Left)
- Arm - Elbow (Right)
- Arm - Elbow (Left)
- Arm - Forearm (Right)
- Arm - Forearm (Left)
- Wrist (Right)
- Wrist (Left)
- Hand (Right)
- Hand (Left)
- Chest
- Abdominal / Stomach
- Groin / Anus
- Leg - Upper (Right)
- Leg - Upper (Left)
- Leg - Knee (Right)
- Leg - Knee (Left)
- Leg - Lower (Right)
- Leg - Lower (Left)
- Ankle (Right)
- Ankle (Left)
- Foot (Right)
- Foot (Left)
- Shoulder (Left)
- Shoulder (Right)
- Other
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Please describe injury location
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Describe this injury or illness
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What was the cause of this injury or illness?
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Pictures of wound or area incident happened
Employees Involved
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Full Name
Witnesses
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Full Name
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Contact phone number
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What is this person's relation to the incident? (select all that apply)
- Reporter of incident
- Injured person
- Witness
- Primary person involved
- Secondary Involvement
- On-duty supervisor
- Investigator
- Suspect
- Other
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Describe this person's relation to the incident
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Please describe this person's involvement with the incident, including all relevant information
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Picture of ID
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Additional Details?
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How could this incident been prevented?
Corrective Actions
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Were disciplinary measures taken?
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Actions taken/ police report number?
Sign Off
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Further action/follow-up/investigation required?
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Name of person/people to follow up
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Name & Signature of Reporter
