Automotive or field equipment
Exact Description of Occurence
According to you what was the unsafe situation or action?
What are the preventive and corrective procedures?
Are instructions been given before starting the job?
Is Medical Treatment required?
Name of Clinic or Hospital
Keystone Concrete Injury and Incident Report 2013
Please note that this checklist is a hypothetical example and provides basic information only. It is not intended
take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or
or other applicable laws. You should also seek your own professional advice to determine if the use of such
permissible in your workplace or jurisdiction.