Keystone Concrete Injury and Incident Report 2013

Injury Report

• Incident #

• Employees information Name and Social Security

  Sign

• Supervisors Name

  Sign

• Reported By

  Sign

• Select date

  Date
• Add location
  Address

Incident Report

Incident Type

• Injury

• First Aid

• Automotive or field equipment

• Near Miss

• Environmental

Exact Description of Occurence

• According to you what was the unsafe situation or action?

• What are the preventive and corrective procedures?

• Witness of incident

  Yes

  No

  N/A

• Name of witness
  

• Are instructions been given before starting the job?

  Yes

  No

  N/A

• Is Medical Treatment required?

  Yes

  No

  N/A

• Name of Clinic or Hospital