Information

  • Employee Name

  • Social Security number

  • Incident location

  • Investigation Conducted on

  • Prepared by

  • Initial date and time of injury/incident

  • Date and time supervisor was notified

  • When was Safety notified.

  • Was there an injury?

  • Did he/she receive medical treatment? If yes, please briefly describe treatment and where it was given.

  • Where on site did injury occur?

  • Please describe in detail the incident and/or injury.

  • Please list all witnesses

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.