SMI EMPLOYEE INCIDENT REPORT

• Document No.

• Report Title

• Jobsite

• Conducted on

  Date

• Prepared by

GENERAL INFORMATION

• DATE AND TIME OF INCIDENT

  Date

• DATE AND TIME INCIDENT WAS REPORTED

  Date

• JOBSITE

• LOCATION
  Address

• EMPLOYEE NAME | TITLE

• SUPERVISOR NAME | TITLE

• WITNESSES NAMES

INCIDENT INFORMATION

• DESCRIBE TASK BEING PERFORMED WHEN INCIDENT OCCURRED.

• DESCRIBE HOW THE INCIDENT OCCURRED.

• DESCRIBE HOW THE INJURY OCCURRED. (IF APPLICABLE)

• DESCRIBE INJURIES. (IF APPLICABLE)

• WERE ALL NECESSARY SAFETY DEVICES AND PROTECTIVE SYSTEMS BEING USED?

  YES

  NO

• WAS EMPLOYEE USING ALL REQUIRED PERSONAL PROTECTION EQUIPMENT?

  YES

  NO

• WERE ALL SAFETY PRACTICES AND RULES BEING FOLLOWED?

  YES

  NO

• HAS THIS EMPLOYEE RECEIVED TRAINING TO PREVENT THIS TYPE OF ACCIDENT?

  YES

  NO

MEDIA

• PHOTOS OF INCIDENT (IF APPLICABLE)

PHOTO

• Add media

  Media

• DESCRIPTION OF PHOTO

CERTIFY

• EMPLOYEE'S SIGNATURE

  Sign

• SUPERVISOR'S SIGNATURE

  Sign