Information

  • Preliminary Incident Notification

  • TES-MS-1022

INCIDENT DETAILS

  • Date of Incident

  • Time of Incident

  • Incident Location

  • Product Line

  • Incident Type

  • INJURED PERSON (IP) DETAILS (ONLY COMPLETE IF REPORTING AN INJURY OR ILLNESS)

  • INJURED PERSON
  • Employee Name

  • Job Title

  • Supervisors Name

  • INCIDENT DETAILS (Include information about activities being performed during incident)

  • IMMEDIATE ACTIONS TAKEN (describe in detail)

  • Add Pictures

  • INCIDENT DETAILS (Include information about activities being performed during incident)

  • IMMEDIATE ACTIONS TAKEN (describe in detail)

  • Add Pictures

  • INCIDENT DETAILS (Include information about activities being performed during incident)

  • IMMEDIATE ACTIONS TAKEN (describe in detail)

  • Add Pictures

  • SUMMARY - TO BE COMPLETED BY THE HSSE PERSONNEL

  • Person Completing Report

  • Job Title

  • Incident Injury Classification

  • Quantity Contained ( Gallons )

  • Quantity Outside Containment ( Gallons )

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.