To whom was the incident reported?
Location of incident. (Specify site location)
Supervisor's Phone Number
Was there any witness(es)? If yes, provide name(s).
Name (Person 1):
Time on job: (Yrs & Mos)
- First-Aid only
- Near miss
- Lost time
- OH&S Reportable
- Returned to Work
- Modified Duties
- Sent Home
- To Doctor
- To Hospital
Medication prescribed? If yes list medications.
Detail any first-aid or medical treatment administered. (Provide names)
- Private Property
Estimated cost of damage:
Detailed description of incident. (Include environmental conditions at time of incident)
Immediate (Direct Causes):
Contributing (underlying) Factors:
Corrective Action (Include detail description of action and person(s) responsible for actions)
What could have potentially happened?