Incident Report

• Document No.

• Location of Incident

• Location

  SILC

  SEMI

• Conducted on

  Date

• Incident Report Done By

• Name(s) of employee(s) involved:

• Date & Time of incident

  Date

• Department/Area of Incident

Employer (Check all that apply)

• Celadon Logistics

• Contractor

• Temporary

• Other

• Detailed description of accident (What occurred, who was involved, what happened):

• Employee Comments (What do you think was the cause? How could it have been prevented?):

• Did you report this incident to your supervisor as soon as possible?

  Yes

  No

  N/A

• If not, explain why it was not reported:

• Did you accept medical treatment?

  Yes

  No

  N/A

• Were you wearing the required personal protective equipment?

  Yes

  No

  N/A

• Were you injured as a result of this incident?

  Yes

  No

  N/A

• Were you performing your normal duties?

  Yes

  No

  N/A

• Is an alcohol/drug test required?

  Yes

  No

  N/A

Property involved (Check all involved)

• PIV

• Crane

• Racking

• Product

• Trailer

• Guard Rails/Dock Plates/Pillars

• Pedestrian/worker

• Other

• Describe Damage:

• Equipment Inspected?

  Yes

  No

  N/A

• Maintenance requested?

  Yes

  No

  N/A

• Type of incident?

  Select Equipemt impact, no damage Cuts, bruises, first-aid Fall, no damage Slips, trips, falls (Requires doctor) Freight Damage Property Damage

  • Equipemt impact, no damage
  • Cuts, bruises, first-aid
  • Fall, no damage
  • Slips, trips, falls (Requires doctor)
  • Freight Damage
  • Property Damage

• Employee Signature

  Sign

• Safety Committee Member Signature

  Sign

• Supervisors Signature

  Sign