INCIDENT REPORT

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel involved

SECTION I

• Name

• Date and time of incident

  Date

• Date and time incident was reported.

  Date

• To whom was the incident reported?

• Location of incident. (Specify site location)
  Address

• Was there any witness(es)? If yes, provide name(s).

  Select Yes No N/A

  • Yes
  • No
  • N/A

• Did you ask witnesses to provide written statement immediately?

  Yes

  No

  N/A

• Please ask them to send statement asap

  Yes

  No

  N/A

DETAILS OF INJURY, IF APPLICABLE

• Describe injury.

• (additional space)

• (additional space)

• Was First Aid Required?

  Yes

  No

  N/A

• Detail any first-aid or medical treatment administered. (Provide names)

DETAILS OF DAMAGE, IF APPLICABLE

• Property Damage:

  None

  Minor

  Serious

  Major

• Photo of damage.

  Media

• Property Damage:

  N/a

  Vehicle

  Equipment

  Private Property

• Photo of damage.

  Media

• Detailed description of incident. (Include environmental conditions at time of incident)

• Environmental photo:

  Media

• Immediate (Direct Causes):

• Direct cause photo:

  Media

• Direct cause photo:

  Media

ANALYSIS

• Contributing (underlying) Factors:

• Contributing factors photo:

  Media

• Corrective Action (Include detail description of action and person(s) responsible for actions)

• What was the potential for severity?

  Minor

  Serious

  Major

• What could have potentially happened?

• What is the probability of reoccurrance?

  Remote

  Improbable

  Probable

• Any additional comments?

• Name & Signature of person completing report

  Sign

• Date and time of approval

  Date

• Approver's signature

  Sign