SMI SUPERVISOR INCIDENT REPORT

• Document No.

• Report Title

• Jobsite

• Conducted on

  Date

• Prepared by

GENERAL INFORMATION

• TYPE OF INCIDENT

  Select NEAR MISS PROPERTY DAMAGE FIRST AID DR VISIT EMERGENCY FATALITY

  • NEAR MISS
  • PROPERTY DAMAGE
  • FIRST AID
  • DR VISIT
  • EMERGENCY
  • FATALITY

• DATE AND TIME OF INCIDENT

  Date

• DATE AND TIME REPORTED

  Date

• JOBSITE

• LOCATION OF INCIDENT
  Address

INCIDENT OBSERVATIONS

• WHAT DID YOU OBSERVE AT THE INCIDENT SITE?

• WHAT DID YOU DO DURING/AFTER THE INCIDENT?

• WHY DID THE INCIDENT OCCUR?

• WHY DID THE ACCIDENT OCCUR? (IF APPLICABLE)

• WHAT ACTIONS HAVE OR WILL BE TAKEN TO PREVENT RE-OCCURRENCE?

CERTIFY

• SUPERVISOR'S SIGNATURE

  Sign

• SAFETY COORDINATOR'S SIGNATURE

  Sign