Exposure Details:
Date of Incident:

Department where incident occured:




Presented for treatment:

Date Reported:

Reported To:

Type of Device/Equipment:

Brand Name of Device/Equipment:

Location of Incident:
Describe What Happened

Enter Discription:

Was any equipment involved?

Pertinent Photos:

What action was taken immediately after the incident?

Enter description

Can any improvements be made as a result of this occurrence?


Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment; or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is permissible in your workplace or jurisdiction.