PPPer - Incident Report Form

• Copies forwarded to

  Select General Manager Director of Finance Director of Rooms Director of Engineering Director of HCD Director of Revenue Director of F&B Director of S&M Executive Chef PPPER Duty Managers

  • General Manager
  • Director of Finance
  • Director of Rooms
  • Director of Engineering
  • Director of HCD
  • Director of Revenue
  • Director of F&B
  • Director of S&M
  • Executive Chef
  • PPPER Duty Managers

• Reported Created On

  Date

• Report Created By

• Incident details and investigations MUST be completed prior to end of shift by Department Head, Supervisor, or Duty Manager.

• TYPE OF INCIDENT

  Select NEAR MISS INJURY/ILLNESS PROPERTY/EQUIPMENT DAMAGE 󠅧 󠅧 ENVIORNMENTAL OTHER

  • NEAR MISS
  • INJURY/ILLNESS
  • PROPERTY/EQUIPMENT DAMAGE 󠅧 󠅧
  • ENVIORNMENTAL
  • OTHER

• SPECIFY OTHER

DETAILS OF ASSOCIATE INVOLVED

• NAME

• DATE OF BIRTH

  Date

• SEX

  MALE

  FEMALE
• ADDRESS
  Address

• HOME PHONE

• MOBILE PHONE

• POSITION/DEPARTMENT

• DATE HIRED

  Date

• STATUS

  FT

  PT

  CS

• SIGNATURE

  Sign

DETAILS OF INCIDENT

• DATE AND TIME OF INCIDENT

  Date

• LOCATION OF INCIDENT

• DATE INCIDENT REPORTED

  Date

• INCIDENT REPORTED TO

• FULL DESCRIPTION OF INCIDENT

DETAILS OF WORK-RELATED INJURY/ILLNESS

• Add drawing

  Drawing

• BODY PART INJURED

  Select EYE HEAD CHEST BACK ABDOMEN ARM HAND/FINGER LEG FOOT/TOE RESPIRATORY OTHER

  • EYE
  • HEAD
  • CHEST
  • BACK
  • ABDOMEN
  • ARM
  • HAND/FINGER
  • LEG
  • FOOT/TOE
  • RESPIRATORY
  • OTHER

• TYPE OF INJURY/ILLNESS

  Select LACERATION ABRASION PUNCTURE BURN FRACTURE STRAIN/SPRAIN AMPUTATION FOREIGN BODY HERNIA CONTUSION OTHER

  • LACERATION
  • ABRASION
  • PUNCTURE
  • BURN
  • FRACTURE
  • STRAIN/SPRAIN
  • AMPUTATION
  • FOREIGN BODY
  • HERNIA
  • CONTUSION
  • OTHER

• SEVERITY OF INJURY/ILLNESS

  Select FIRST AID TREATMENT (ONSITE) MEDICAL TREATMENT (DOCTOR/HOSPITAL) LOST TIME INJURY/ILLNESS

  • FIRST AID TREATMENT (ONSITE)
  • MEDICAL TREATMENT (DOCTOR/HOSPITAL)
  • LOST TIME INJURY/ILLNESS

• NAME OF DOCTOR

• NAME OF HOSPITAL

• DATE ATTENDED

  Date

DETAILS OF PROPERTY/EQUIPMENT DAMAGE

• PROPERTY/EQUIPMENT TYPE AND LOCATION

• DESCRIPTION OF DAMGE

INCIDENT REPORT COMPLETED BY

• NAME, SIGNATURE & SIGN DATE

  Sign

• POSITION

• REC

  Yes

  No

  N/A

RECOMMENDED CORRECTIVE ACTION/S

• undefined