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Incident Report
Incident Report
Herb Franz

Incident Report Checklist

Kroeker Farms Limited

Use this Digital Checklist
Download as PDF
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Free Incident Report Checklist

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General Information:
Date of Incident:
Date of Report:

Name of Employee:

Employee Number:

Location of Incident:

Division:

Incident Type:

Personal Injury:

Full Details of Incident:

List of Injuries:

Suggestions for Preventing Incidents of this Type:

Were there witnesses to this incident?

Witness Name:

Witness Phone Number:

Witness Name:

Witness Phone Number:

Were actions taken as a result of this Incident?

Actions taken with the worker as a result of this Incident:

Training completed as a result of this incident:

Names of workers trained

Were there any injuries as a result of this incident?

Names of those injured:

Medical Treatment required?

When?
Where?
  • Dr. C. W. Wiebe Clinic
  • Boundary Trails Health Centre
  • Other

Name of Healthcare Practitioner or Healthcare Facility where medical treatment was received:

Name of doctor / healthcare practitioner:

I certify that, to the best of my knowledge, the above information is true and complete Signature of Employee:
I certify that, to the best of my knowledge, the above information is true and complete Signature of Manager:

Theft:

Was a Kroeker Farms Vehicle or Piece of Equipment stolen?

Unit Number:

Year:

License Number:

Estimated Damage:

Actual Damage:

Make:

Serial Number (if no Unit Number):

Full Details of the Incident:

List of Damages or Injuries:

Suggestions for Preventing Incidents of this Type:

Were there Witnesses to this Incident?

Witness Name:

Witness Phone Number:

Witness Name:

Witness Phone Number:

Was this Incident Reported to the police?

Select date

Was this Incident Reported to the Insurance Company?

Select date
I certify that, to the best of my knowledge, the above information is true and complete Signature of Employee:
I certify that, to the best of my knowledge, the above information is true and complete Signature of Manager:

Vandalism:

Was a Kroeker Farms vehicle or piece of Equipment Vandalized?

Unit Number:

Year:

License Number:

Estimated Damage:

Actual Damage:

Make:

Serial Number (if no Unit Number):

List of Damages or Injuries:

Suggestions for Preventing Incidents of this Type:

Full Details of Incident:

Were there any Witnesses to this Incident?

Witness Name:

Witness Phone Number:

Witness Name:

Witness Phone Number:

Was this Incident Reported to the Police?

Select date

Was this Incident Reported to the Insurance Company?

Select date
I certify that, to the best of my knowledge, the above information is true and complete Signature of Employee:
I certify that, to the best of my knowledge, the above information is true and complete Signature of Manager:

Accidental Damage:

Was a Kroeker Farms Vehicle or Piece of Equipment Damaged?

Unit Number:

Year:

License Number:

Estimated Damage:

Actual Damage:

Make:

Serial Number (if no Unit Number)

Full Details of this Incident:

List of Damages and / or Injuries:

Suggestions for Preventing Incidents of this Type:

Was there Another Party Involved in this Incident?

Other Party's Name:

Other Party's Phone Number:

Make:

Serial Number:

Year:

License Number:

Estimated Damage:

Actual Damage:

Were there any Witnesses to this Incident?

Witness Name:

Witness Phone Number:

Witness Name:

Witness Phone Number:

Were actions taken as a result of this Incident?

Action taken with the Worker as a result of this Incident:

Training Completed as a Result of this Incident:

Names of Workers Trained

I certify that, to the best of my knowledge, the above information is true and complete Signature of Employee:
I certify that, to the best of my knowledge, the above information is true and complete Signature of Manager:

Close Calls:

Was there a Kroeker Farms Vehicle or Piece of Equipment Involved I this Incident?

Unit Number:

Year:

License Number:

Estimated Damage:

Actual Damage:

Make:

Serial Number (if no Unit Number):

Full Details of this Incident:

List of Damages or Injuries:

Suggestions for Preventing Incidents of this Type:

Were any actions taken as a result of this Incident?

Action taken with the worker as a result of this Incident:

Training completed as a result of this Incident:

Names of Workers trained:

I certify that, to the best of my knowledge, the above information is true and complete Signature of Manager:
I certify that, to the best of my knowledge, the above information is true and complete Signature of Employee:
Incident Report
Herb Franz

Incident Report

Kroeker Farms Limited

Use this Digital Checklist
Download as PDF
Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment; or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is permissible in your workplace or jurisdiction.

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