Name of employee:

Worker Status:
Number of occurrence:
Category of event:

Name of immediate supervisor:

Observation Detail

Description of event / What happened:

Corrective action:
Add media

Witnesses to the event:

Further corrective action required, or taken:

Person Signing:
Name and Signature
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.