To whom was the incident reported?
Was there any witness(es)? If yes, provide name(s).
Name (Person 1):
Time on job: (Yrs & Mos)
Employee Disposition Status:
Medication prescribed? If yes list medications.
Detail any first-aid or medical treatment administered. (Provide names)
Was there any Property Damage?
Any equipment involved?
We're there any vehicles involved?
Was any equipment involved?
Equipment Asset number:
Detailed description of just prior to and 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 was the potential for severity?
What could have potentially happened?