Affected Employee Information

  • Name of Employee

  • Employee's Job Title

Incident Information

  • Type of Incident

  • Date and Time of Incident

  • Date and Time Incident was Reported

  • Location of Incident

  • Describe the Accident and How it Occurred

  • Cause of Accident

  • Cause of the Accident

  • Was Personal Protective Equipment Required?

  • Was Personal Protective Equipment Provided?

  • Was Personal Protective Equipment Being used?

  • If PPE was not being used please explain why.

  • Witness(es) Name(s)

  • Was Safety Training Provided to the Affected Employee?

  • Corrective Action to Prevent Reocurrence

  • Pictures of the Scene / Incident

  • Side of Body

  • Part of Body

  • Affected Employee Signature

  • Supervisor Signature

Office Use Only

  • Did the Employee Receive Medical Treatment

  • Did the Employee Return to Work?

  • Date Employee Returned to Work

  • Treating Provider

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