MANFREIGHT POST-INCIDENT REPORT

• Document Ref No.

• Conducted on

  Date

• Prepared by

• Persons involved in investigation

Facts

• Date & time of Incident

  Date

• Location of incident

• Photo

  Media

Employee

• Employee involved

• Job Description

• Type injury

  Select Cut Bruise Break Strain/sprain Scrape Exposure Smash Burn Amputation Other (explain below)

  • Cut
  • Bruise
  • Break
  • Strain/sprain
  • Scrape
  • Exposure
  • Smash
  • Burn
  • Amputation
  • Other (explain below)

• Explain "other"

• Body part

• Medical sought?

  Yes

  No

  N/A

• Employee's immediate supervisor

• Task in progress at time of injury

Property

• Property damaged

• Nature of damage

• Estimated cost to repair/replace

• Actual cost to repair/replace

• Photo

  Media

Incident

• Describe incident

• Cause of accident

• Photo

  Media

• Sketch

  Drawing

Cause

• Weather Condition

• Traffic Condition

• Contributory Cause

• Root Cause

Comments

• Employee comments

• Investigator comments

• Photo

  Media

Signatures

• Investigator

  Sign

• Date completed

  Date