Incident Report Form

• Type of incident:

  Select Injury / Illness Near Miss Property Damage Spill Fire Unsafe Act / Condition

  • Injury / Illness
  • Near Miss
  • Property Damage
  • Spill
  • Fire
  • Unsafe Act / Condition

• Name:

• Date / Time:

  Date

• Shift

  Select A-Shift B-Shift C-Shift D-Shift Production Shipping Maintenance Custodian Production Office

  • A-Shift
  • B-Shift
  • C-Shift
  • D-Shift
  • Production Shipping
  • Maintenance
  • Custodian
  • Production
  • Office

• Gender:

  Male

  Female

• Position / Job Title:

  Select Operator Setup Supervisor Production Production Shipping Maintenance Custodian Office

  • Operator
  • Setup
  • Supervisor
  • Production
  • Production Shipping
  • Maintenance
  • Custodian
  • Office

• Employee Phone Number:

Incident Information

• Action Performed: (threading line, flipping roll, cutting scrap, etc.)

• Describe Incident:

• Location (of incident):

• Injury Type:

  Select Amputation Bruise Concussion Cut Dislocation Fracture Hernia Other Strain /Sprain N/A

  • Amputation
  • Bruise
  • Concussion
  • Cut
  • Dislocation
  • Fracture
  • Hernia
  • Other
  • Strain /Sprain
  • N/A

• Body Part:

  Select Abdomen Arm(s) Back Finger(s) Foot / Feet / Toe / Ankle Groin Hand(s) Head Knee(s) Legs Multiple Other Shoulder Wrist(s) N/A

  • Abdomen
  • Arm(s)
  • Back
  • Finger(s)
  • Foot / Feet / Toe / Ankle
  • Groin
  • Hand(s)
  • Head
  • Knee(s)
  • Legs
  • Multiple
  • Other
  • Shoulder
  • Wrist(s)
  • N/A

• Finger Digit:

  Index (Pointer)

  Middle

  Ring

  Pinky

  Thumb

• Left / Right Body Part

  Left

  Right

  N/A

• Asset / Equipment (If Know)

• Signature

  Sign

• Date

  Date