Information
Incident Report
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Date of Incident:
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Employee(s) Involved in the Incident:
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Employee Number(s) of Those Involved in the Incident (if available):
General Information:
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Date of Incident:
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Date of Report:
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Name of Employee:
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Employee Number:
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Location of Incident:
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Division:
Incident Type:
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Personal Injury:
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Full Details of Incident:
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List of Injuries:
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Suggestions for Preventing Incidents of this Type:
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Were there witnesses to this incident?
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Witness Name:
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Witness Phone Number:
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Witness Name:
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Witness Phone Number:
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Were actions taken as a result of this Incident?
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Actions taken with the worker as a result of this Incident:
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Training completed as a result of this incident:
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Names of workers trained
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Were there any injuries as a result of this incident?
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Names of those injured:
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Medical Treatment required?
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When?
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Where?
- Dr. C. W. Wiebe Clinic
- Boundary Trails Health Centre
- Other
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Name of Healthcare Practitioner or Healthcare Facility where medical treatment was received:
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Name of doctor / healthcare practitioner:
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I certify that, to the best of my knowledge, the above information is true and complete Signature of Employee:
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I certify that, to the best of my knowledge, the above information is true and complete Signature of Manager:
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Theft:
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Was a Kroeker Farms Vehicle or Piece of Equipment stolen?
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Unit Number:
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Year:
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License Number:
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Estimated Damage:
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Actual Damage:
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Make:
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Serial Number (if no Unit Number):
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Full Details of the Incident:
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List of Damages or Injuries:
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Suggestions for Preventing Incidents of this Type:
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Were there Witnesses to this Incident?
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Witness Name:
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Witness Phone Number:
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Witness Name:
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Witness Phone Number:
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Was this Incident Reported to the police?
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Select date
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Was this Incident Reported to the Insurance Company?
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Select date
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I certify that, to the best of my knowledge, the above information is true and complete Signature of Employee:
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I certify that, to the best of my knowledge, the above information is true and complete Signature of Manager:
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Vandalism:
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Was a Kroeker Farms vehicle or piece of Equipment Vandalized?
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Unit Number:
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Year:
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License Number:
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Estimated Damage:
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Actual Damage:
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Make:
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Serial Number (if no Unit Number):
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List of Damages or Injuries:
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Suggestions for Preventing Incidents of this Type:
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Full Details of Incident:
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Were there any Witnesses to this Incident?
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Witness Name:
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Witness Phone Number:
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Witness Name:
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Witness Phone Number:
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Was this Incident Reported to the Police?
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Select date
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Was this Incident Reported to the Insurance Company?
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Select date
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I certify that, to the best of my knowledge, the above information is true and complete Signature of Employee:
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I certify that, to the best of my knowledge, the above information is true and complete Signature of Manager:
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Accidental Damage:
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Was a Kroeker Farms Vehicle or Piece of Equipment Damaged?
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Unit Number:
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Year:
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License Number:
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Estimated Damage:
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Actual Damage:
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Make:
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Serial Number (if no Unit Number)
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Full Details of this Incident:
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List of Damages and / or Injuries:
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Suggestions for Preventing Incidents of this Type:
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Was there Another Party Involved in this Incident?
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Other Party's Name:
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Other Party's Phone Number:
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Make:
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Serial Number:
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Year:
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License Number:
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Estimated Damage:
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Actual Damage:
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Were there any Witnesses to this Incident?
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Witness Name:
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Witness Phone Number:
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Witness Name:
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Witness Phone Number:
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Were actions taken as a result of this Incident?
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Action taken with the Worker as a result of this Incident:
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Training Completed as a Result of this Incident:
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Names of Workers Trained
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I certify that, to the best of my knowledge, the above information is true and complete Signature of Employee:
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I certify that, to the best of my knowledge, the above information is true and complete Signature of Manager:
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Close Calls:
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Was there a Kroeker Farms Vehicle or Piece of Equipment Involved I this Incident?
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Unit Number:
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Year:
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License Number:
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Estimated Damage:
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Actual Damage:
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Make:
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Serial Number (if no Unit Number):
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Full Details of this Incident:
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List of Damages or Injuries:
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Suggestions for Preventing Incidents of this Type:
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Were any actions taken as a result of this Incident?
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Action taken with the worker as a result of this Incident:
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Training completed as a result of this Incident:
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Names of Workers trained:
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I certify that, to the best of my knowledge, the above information is true and complete Signature of Manager:
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I certify that, to the best of my knowledge, the above information is true and complete Signature of Employee:
