Incident Reporting Form

Incident Reporting Form

Use this form to report any workplace accident/injury, incident, close call, or illness.

Return completed form to the Operations Supervisor or ________________________

Type of Report:

□                         □    □      □       □         □

Lost Time/            First Aid     Incident      Near Miss   Observation         Unprofessional

Injury                                                                                                        or Inappropriate                                                                                                                          Behavior

*Details of person involved (to be completed by person injured/involved, if possible)

Person Completing Report: ______________________________________________Date:__________________

Person(s) Involved: ___________________________________________________________________________

Equipment ID (if applicable): _________________________

Event Details

Date of Event: _______________                Location of Event (be specific): ______________________________

Time of Event: ______________                  Witnesses: _______________________________________________

Description of Event (Describe tasks being performed and sequence of events)

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

*If more space is required use the back of this form

Cause of event/injury:

• Unsafe act (activity or movement)?
• Unsafe condition (device or weather)?

Explain:

__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Signature of Employee Student: _________________________________Date: _______________________

Signature of Risk Manager: ____________________________________Date: _______________________