Injury, Accident, Incident Report

• Job Name

• Conducted on

  Date

• Prepared by

• Location
  Address

SECTION I : The Basics

• Name of person involved

• Date and time of incident

  Date

• Date and time incident was reported.

  Date

• Who was the accident first reported to?

• Location of incident. (Specify site location)

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

  Yes

  No

  N/A

SECTION 2: DETAILS OF INJURY / INCIDENT, IF APPLICABLE

• What is the cause of injury?

  Select Struck by Caught by Pinched by Crushed by Impact from fall Cut by

  • Struck by
  • Caught by
  • Pinched by
  • Crushed by
  • Impact from fall
  • Cut by

• Describe injury.

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

Section 3: ANALYSIS

• Description of incident.

  Yes

  No

  N/A

• Severity of injury

  First Aid

  Reportable (work comp)

  OSHA Recordable

• Nature of injury

  Select SLIP - TRIP - FALL Pinched by Crushed by Struck by Ergonomic (repetitive, or MSD) Cut by Burned by (thermal)

  • SLIP - TRIP - FALL
  • Pinched by
  • Crushed by
  • Struck by
  • Ergonomic (repetitive, or MSD)
  • Cut by
  • Burned by (thermal)

• Contributing (underlying) Factors:

• Contributing factors photo:

  Media

• What could be done to prevent this from occurring again?

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

• What was the potential for severity?

  Minor

  Serious

  Major

• What could have potentially happened?

• What is the probability of reoccurrance?

  Remote

  Improbable

  Probable

• Select date

  Date

• Signature

  Sign