Date and time of incident

Nature of the incident (i.e. fall, struck by, caught between, slip/trip)

Add media

What Happened

How / Why did this happen:

What is being done to prevent recurrence?

Was there any witness(es)? If yes, provide name(s).

Distribution List:

Ray Boehm

Shane Spears

Ren Harwell

Larry Havel

Justin Fuhrman

Denver Moody

Charles Berg

Pete Hyatt

Aaron Fretwell

Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment; or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is permissible in your workplace or jurisdiction.