Title Page
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Job
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Conducted on
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Prepared by
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Location
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NOTE:
This general template can be used for all incidents, however it is important to check with your state regulatory body requirements and/or Insurer as to the legal reporting requirements. You can modify this template to suit your workplace needs.
Incident Details
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Enter job description
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Date and time of incident
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What was the Incident/ Near Miss?
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Were there any injuries?
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Description of injury
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Take photo of injury
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Was there any damage to property or plant?
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Description of damage
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Take photo of damage
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What caused the incident?
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Take photo of surrounding environment including any annotations
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What actions will be taken to eliminate future repeats of the incident?
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Management comments
Sign Off
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Signed off by supervisor when corrective actions have been adopted and monitored
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Supervisor sign off