SECTION I

  • Date and time of incident

  • Date and time incident was reported.

  • To whom was the incident reported?

  • Location of incident. (Specify site location)

  • Supervisor's Name

  • Supervisor's Phone Number

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

  • Witness
  • Name and Address

PERSON(S) INVOLOVED

  • Person

  • Person
  • Name

  • Phone:

  • Sex:

  • Age;

  • Job Title:

  • Time on job: (Yrs & Mos)

  • Job Status:

  • Classification:

  • Employee Disposition Status:

  • Medication prescribed? If yes list medications.

  • List Medications

NATURE OF INJURY

  • Describe injury.

  • Detail any first-aid or medical treatment administered. (Provide names)

  • Property Damage:

  • Photo of damage.

  • Property Damage:

  • Photo of damage.

  • Estimated cost of damage:

  • Machinery /Vehicle
  • Machinery/ Vehicle ID:

  • Make/Model:

  • Age:

  • Detailed description of incident. (Include environmental conditions at time of incident)

  • Environmental photo:

  • Environmental photo:

  • Immediate (Direct Causes):

  • Direct cause photo:

  • Direct cause photo:

  • Contributing (underlying) Factors:

  • Contributing factors photo:

  • Corrective Action (Include detail description of action and person(s) responsible for actions)

  • What was the potential for severity?

  • What could have potentially happened?

  • What is the probability of reoccurrance?

  • Date

  • Signature

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