1a. Employee’s information

Employee’s name
Employee Position
Name of Supervisor/Manager

1b. Person Reporting Incident

Employee Name
Employee Position

2. Injured/Affected persons

Last name / First name / Job title /
a)
b)

3. Place, date, and time of incident (If there are multiple preceding incidents, please use Part 6 of this form for details.)

Location where incident occurred
Date of incident (mm-dd-yy) / Time of incident / a.m.
p.m.

5. Previous History

Has the person in question been involved in any other incident? / If yes, was the incident reported? / Last incident reported to:

4. Type of incident (select all that apply)

Sexual Harassment
Discrimination to a worker
Injury to a worker
Major structural failure or collapse
Major release of hazardous substance / Driving incident
Minor injury or no injury but had potential for causing serious injury
Injury requiring medical treatment beyond first aid
Damaged Equipment/Dysfunctional Office Equipment
Accident causing personal injury
Other:

5. Witnesses

Last name / First name / Job title /
a)
b)
c)
d)

6. Sequence of events that preceded the incident

Describe events earlier that day or even in previous days that led up to the incident. Examples may include events such as training given or changes in equipment, procedures, physical contact made or company management.

7. Unsafe conditions, acts, or procedures that significantly contributed to the incident

Describe anything, or the absence of anything, that contributed to the hazard such as poor visibility, using equipment without guards, or the lack of safe work procedures.

8. Full description of the incident

Briefly, summarize the sequence of events, the unsafe factors, and the resulting injury, if any.

9. Corrective actions identified and taken to prevent recurrence of similar incidents

Action / Action assigned to
(name and job title) / Expected completion date
(yyyy-mm-dd) / Completed date
(yyyy-mm-dd) /
a)
b)

10. Signatures Required

Person Involved in Incident / Date / Contact Number /
Person Reporting Incident / Date / Contact Number /

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