To whom was the incident reported?
Location of incident. (Specify site location)
Was there any witness(es)? If yes, provide name(s).
Detail any first-aid or medical treatment administered. (Provide names)
Detailed description of 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?
What is the probability of reoccurrance?