INCIDENT REPORT FORM - SIDESHIFT

• Site conducted

  Select

• Conducted on

  Date

• Prepared by

• Location
  Address

• Person Completing Report

  Yes

  No

  N/A

• Name:

• Contact Number:

• Date:

  Date

• Supervisors name:

• Department:

• Name of injured or affected person:

• Address:

• Contact number:

• Date of Birth:

  Date

• Occupation:

• Date Incident Occurred?

  Date

• Time: Place:

  Date

• Type of incident:

• INJURY PROPERTY DAMAGE CAR DAMAGE WORK RELATED ILLNESS NEAR MISS

  Yes

  No

  N/A

INJURY PROPERTY DAMAGE CAR DAMAGE WORK RELATED ILLNESS NEAR MISS

• Details of incident or injury sustained:

• Were any emergency services called to the incident? (If yes provide details)

  Yes

  No

  N/A

• What action was taken?

• By whom:

• Full description of action or treatment given:

• Was the injured party referred for further treatment?

  YES

  NO

• If so where to:

• Injured or affected person’s full description of the accident:

WITNESS

• Name of witness:

• Address:

• Contact number:

• Witness full description of the accident:

• Were there any other witnesses?

  YES

  NO

• Name of witness:

• Contact number:

• Was supervisor informed?

  YES

  NO

• Was safety protection being used or worn at the time? YES/NO If yes, what:

• Was the safety protection adequate? YES/N0

  Yes

  No

  N/A

• Injured or affected person’s signature:

  Sign

• Witness signature:

  Sign

• Person filing report signature:

  Sign