Warehouse Accident: Employee Report

• Name

• Current Date & Time

  Date

Personal Information

• Phone Number

• Street

• City

• State

• Zip

• Position

• What time did you start your shift?

  Date

• # of days since last day off

Incident Details

• What type of accident are you reporting?

  Rack Damage

  Equipment Damage

  Facility Damage

  Near Miss

  Other

• Other

• When did the incident occur?

  Date

• Who did you report the incident to?

• When did you report the incident?

  Date

• Describe the incident. Please be specific.

• How could the incident be prevented?

• Location incident occured

  Select Freezer Cooler Dry Dock Break Room Front Office Area Other

  • Freezer
  • Cooler
  • Dry
  • Dock
  • Break Room
  • Front Office Area
  • Other

• Other

• Are there any witnesses?

  Yes

  No

• If yes, please provide a name and contact number. If no, mark NA.

• Did adverse conditions (noise, light, traffic, etc.) impact this incident?

  Yes

  No

• If yes, please describe. If no, mark NA.

• Hazardous Material Spill?

  Yes

  No

  Unsure

• Equipment #. Mark 0 for NA

• Describe any damages

• Was another person involved in the incident?

  Yes

  No

  Not Applicable

• If yes, please list name & contact number. If no, mark NA.

Media

• Add any pictures here.

  Media

• Sketch the incident.

  Drawing

Employee Signature: By signing below, you certify that the information provided in this report is a true and correct statement of the facts and that you made such statement of you own free will.

• Employee

  Sign

Supervisor Signature: By signing below, you verify that you have reviewed the incident with the employee.

• Supervisor

  Sign