£*£ Incident Investigation Form

• Conducted on

  Date

• Prepared by

• Injured Worker's First & Last Name:

• Occupation:

• Years Experience in Occupation:

• Full Address (Street, City & Postal Code):

• Date of Occurance:

  Date

• Date Reported:

  Date

• Select all that apply

  Select Hazardous Situation Incident First Aid Health Care Lost-Time Critical Injury

  • Hazardous Situation
  • Incident
  • First Aid
  • Health Care
  • Lost-Time
  • Critical Injury

• Describe what happened and, if applicable, describe injury. Attach an accident/incident diagram, if appropriate.

• Describe the nature, date, and time of first aid treatment, if applicable.

• Signature of person reporting incident:

  Sign

Part of Body Injured:

• Head

• Eye

• Neck

• Shoulder

• Upper back

• Lower back

• Upper arm

• Elbow

• Lower arm

• Wrist

• Hand/fingers

• Hip

• Upper leg

• Knee

• Lower leg

• Ankle/foot

• Please specify RIGHT, LEFT, or BOTH where applicable