Title Page
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Site conducted
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Conducted on
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Reporting supervisor
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Did the incident happen on this date?
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When did the incident occur?
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Is there an aisle location?
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What aisle did this occur?
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Name of employee(s) involved
General Information
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Did the employee report this directly?
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Who reported this?
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Are they a full-time employee?
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What agency do they work for?
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Have they been notified?
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Please contact the correct agency.
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Were there any witness' to the event?
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Please collect a separate hand written statement from each person describing the incident.
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What are the name(s) of the witness?
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What time did the employees shift begin?
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What time did the incident occur?
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Were safety protocols being followed?
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Which policy was being violated?
- Housekeeping
- Fall Protection
- Powered Industrial Trucks
- Fire Extinguisher
- Hazard Communication
- Lock Out/Tag Out
- Confined Space
- Material Handling
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Was the employee sent for a drug screen?
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What time were they sent?
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When did they return?
Incident Information
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An Accident is an incident that caused an injury or damage
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Damage, in a single event, that needs repaired
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A Near Miss is an event that could have caused an injury or accident
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Is this an accident, near miss or did an accident cause damage?
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If the employee needs assistance call 911
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Is this an injury or an illness?
- Injury
- Illness
- Damage
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What body part was affected
- Head
- Left Arm
- Right Arm
- Right Hand
- Left Hand
- Torso
- Left Leg
- Right Leg
- Left Foot
- Right Foot
- Back
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Did this require more than first aid?
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How do you qualify the injury?
- Minor
- Moderate
- Serious
- Severe
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What type of injury was this?
- Amputation
- Contusion (Hit by something)
- Crushing
- Impalement (Do Not Remove Object call 911)
- Laceration (cut)
- Sprain or strain (muscle or joint)
- Other
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Was there a piece of equipment involved
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Which type?
- Walkie Rider
- Sit Down Forklift
- Reach Truck
- Order Picker (Cherry Picker)
- Turret Truck
- Box Cutter (Knife)
- Hand Pallet Jack
- Other
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What is the number?
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What is the number?
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What is the number?
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What is the number?
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What is the number?
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Please describe. Add photo if possible.
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Was this caused by an exposure?
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What was the exposure to?
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What caused the illness?
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What equipment was involved?
- Walkie Rider
- Sit Down Forklift
- Reach Truck
- Order Picker (Cherry Picker)
- Turret Truck
- Box Cutter (Knife)
- Hand Pallet Jack
- Other
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What is the number(s)?
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Would this have caused an injury or damage?
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What type of injury could have been caused?
- Amputation
- Contusion (Hit by something)
- Crushing
- Impalement (Do Not Remove Object call 911)
- Laceration (cut)
- Sprain or strain (muscle or joint)
- Other
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Please describe.
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What would the severity have been?
- Minor
- Moderate
- Serious
- Severe
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What would have been damaged?
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What type of building damage?
- Structural (wall, doorway, etc.)
- Racking (cross-brace)
- Other
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Please describe
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What would the severity be had this happened?
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Where did this occur?
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What could the severity have been?
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What type of equipment?
- Walkie Rider
- Sit Down Forklift
- Reach Truck
- Order Picker (Cherry Picker)
- Turret Truck
- Box Cutter (Knife)
- Hand Pallet Jack
- Other
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Please describe.
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What would the severity be had this happened?
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Which product would have been affected?
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How much product would have been affected?
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What is the location?
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What was damaged and where?
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Give a brief description of the incident.
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Please add photo's of the involved area or equipment. Do not take photo's of an injury.
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Did you take photo's of directions and placements along with equipment numbers or identification and locations?
Cause and Action
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Do you know the cause?
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What was the cause?
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Were there underlying conditions which contributed to this?
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What conditions?
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What is a recommended corrective action for this?
