SECTION I

  • Name

  • Date and time of incident

  • Date and time incident was reported.

  • Approximate Length of employment, in months

  • Name and address of hospital, if applicable.
  • Photo of doctor's release note.

  • To whom was the incident reported?

  • Location of incident. (Specify site location)

  • Was there any witness(es)? If yes, provide name(s).

  • Activity/ task engaged in at time of incident/ accident

  • Employee's normally assigned task

  • Related training received by employee

  • Date of training

DETAILS OF INJURY, IF APPLICABLE

  • Describe injury.

  • Detail any first-aid or medical treatment administered. (Provide names)

  • Immediate action taken

DETAILS OF DAMAGE, IF APPLICABLE

  • Property Damage:

  • Photo of damage.

  • Property Damage:

  • Photo of damage.

  • Vehicle ID:

  • Detailed description of incident. (Include environmental conditions at time of incident)

  • Environmental photo:

  • Immediate (Direct Causes):

  • Direct cause photo:

  • Direct cause photo:

ANALYSIS

  • Contributing (underlying) Factors:

  • Contributing factors photo:

  • Corrective Action (Include detail description of action and person(s) responsible for actions)

  • What was the potential for severity?

  • What could have potentially happened?

  • What is the probability of reoccurrance?

  • Any previous, similar, or related incidents/ accidents

  • Date of previous incident

  • Actions taken to prevent this or similar incidents/ accidents

  • Any additional recommendations

  • Signature

  • Select date

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