Title Page
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Client / Site
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Conducted on
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Prepared by
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Location
Employee information
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Employee Name:
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Phone number:
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How long have you worked for JEI:
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Do you have a job at another company:
Incident description
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Incident date:
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Please describe the incident:
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Describe step by step what led up to the incident taking place:
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Did anyone witness the incident:
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Name & Phone number of witness:
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Name & Phone number of witness:
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Were pictures taken of the incident scene:
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Please attach pictures
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What could have prevented this incident:
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Was this incident the result of a third party's actions:
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If yes, who:
Injury description
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What parts of your body were injured:
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Have you injured this part of you body before:
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Is medical attention beyond first-aid needed:
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Name of medical facility where medical attention was sought:
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Were you using the required PPE for the task:
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Were photos taken of the injury:
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Please attach photos of the injury
Signatures
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Supervisor signature:
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Employee Signature:
