Warehouse Occurrence: Employee Report

• Name

• Current Date & Time

  Date

Occurrence Details

• What type of occurrence are you reporting?

  Select INCIDENT (damage to property, vehicles or stock) ACCIDENT (involving an injury to a person) NEAR MISS (when an accident or incident occurred but no-one or nothing was damaged) HAZARD (when an item or occurrence could cause potential harm)

  • INCIDENT (damage to property, vehicles or stock)
  • ACCIDENT (involving an injury to a person)
  • NEAR MISS (when an accident or incident occurred but no-one or nothing was damaged)
  • HAZARD (when an item or occurrence could cause potential harm)

• Was anybody injured?

  Yes

  No

• When did the occurrence take place?

  Date

• Where did the occurrence happen?

  Bingley

  Parkmount

  Skipton

  Offsite

  Other

• Describe the occurrence. Please be specific.

• Has the Occurrence area been cordoned off?

  Yes

  No

• Was another person involved in the incident?

  Yes

  No

• Were there any witnesses?

  Yes

  No

• Was any equipment involved in the occurrence?

  Yes

  No

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

  Yes

  No

• Describe any damages to Property, machinery or stock.

• Who did you report the incident to?

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