To whom was the incident reported?
Location of incident. (Specify site location)
Was there any witness(es)? If yes, provide name(s).
Name (Person 1):
Time on job: (Yrs & Mos)
Medication prescribed? If yes list medications.
Detailed deskription of Incident
Describe injury. (If applicable)
Detail any first-aid or medical treatment administered. (Provide names)
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?