WORKPLACE INCIDENT REPORT FORM

INSTRUCTIONS

Fill out this form to report a workplace incident that resulted in injury, illness, or a near miss. Return completed form to:

THIS FORM SERVES TO DOCUMENT select all that apply
LOST TIME / INJURY	FIRST AID	INCIDENT	CLOSE CALL	OBSERVATION

INDIVIDUAL AFFECTED To be filled in by person injured / involved, if possible.

NAME OF PERSON COMPLETING REPORT	SUPERVISOR NAME	DATE OF REPORT
PERSON(S) INVOLVED	EQUIPMENT / VEHICLES INVOLVED

INCIDENT DETAILS

LOCATION	DATE OF INCIDENT	TIME
WITNESSES
INCIDENT DESCRIPTION Describe tasks being performed and sequence of events. Attach additional pages as necessary.
Was event / injury caused by an unsafe act (activity or movement or an unsafe condition, i.e., machinery or weather)?

TO BE COMPLETED ONLY IF LOST TIME / INJURY OR FIRST AID WAS REQUIRED
TYPE OF INJURY SUSTAINED:
CAUSE OF LOST TIME / INJURY OR FIRST AID:
Was medical treatment necessary?	If yes, name of hospital / physician:
YES	NO

EMPLOYEE SIGNATURE	DATE	SUPERVISOR SIGNATURE	DATE

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