Incident Report Copy

• Document No.

• Incident Report

• Client / Site

• Conducted on

  Date

Investigation Details

• Please enter the date and time of this investigation.

  Date

• What type of incident are you investigating?

  Select Accident Near Miss Exposure Property Damage Vandalism

  • Accident
  • Near Miss
  • Exposure
  • Property Damage
  • Vandalism

• Name of owner of property that was damaged?

• Was the injured person an employee of Henry Bros. Co.?

  Yes

  No

• Name of firms involved with the incident.

• How many people were injured?

Incident Details

• Name of injured

• Name of persons involved at time of occurrence?

• Photo of Sign- In Sheets ( If Available).

  Media
• Address and location description?
  Address

• What type of medical treatment was given?

  Select First Aid CPR AED Ambulance Urgent Care Emergency Room N/A

  • First Aid
  • CPR
  • AED
  • Ambulance
  • Urgent Care
  • Emergency Room
  • N/A

• When did the incident occur?

  Date

• What part of the body was affected by the injury?

  Select Head Eyes Neck Front Torso Back Right Arm Right hand Left Arm Left Hand Finger Groin Right Leg Right Ankle Right Foot Left Leg Left Ankle Left Foot Toe N/A

  • Head
  • Eyes
  • Neck
  • Front Torso
  • Back
  • Right Arm
  • Right hand
  • Left Arm
  • Left Hand
  • Finger
  • Groin
  • Right Leg
  • Right Ankle
  • Right Foot
  • Left Leg
  • Left Ankle
  • Left Foot
  • Toe
  • N/A

• Give details of any tasks being carried out at the time of the incident?

• Describe in detail what happened?

• Incident photos

  Media

• Additional facts of interest?

• Inspectors signature

  Sign