Incident Report Checklist
Work Place Incident Details
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Date and time of incident Date
Date and time incident was reported. Date
To whom was the incident reported?
Location of incident. (Specify site location)
Supervisor's Name
Supervisor's Phone Number
SECTION I
- Was there any witness(es)? If yes, provide name(s).
Name (Person 1):
Phone:
PERSON(S) INVOLOVED
Age;
Job Title:
Time on job: (Yrs & Mos)
Classification:
Describe injury.
Detail any first-aid or medical treatment administered. (Provide names)
NATURE OF INJURY
Photo of damage.
Estimated cost of damage:
Vehicle ID:
Make/Model:
Age:
Equipment ID:
Model:
Detailed description of incident. (Include environmental conditions at time of incident)
Environmental photo:
Immediate (Direct Causes):
Direct cause photo:
Contributing (underlying) Factors:
Contributing factors photo:
Corrective Action (Include detail description of action and person(s) responsible for actions)
What could have potentially happened?
Select date Date
Signature
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