Complete each section with accuracy and detail, and submit it to the safety department within [24 hours] of the incident.
Employee's Full Name: | [Employee's Name] |
Job Title: | |
Department/Team: | |
Supervisor's Name: | |
Contact Information: |
Date of Incident: | [Month Day, Year] |
Time of Incident: | |
Exact Location of Incident: | |
Description of the Incident: |
Witness Name(s): | [Your Name] |
Contact Information: | |
Witness Account: |
Nature of Injury: | Minor head contusion |
Part of Body Affected: | |
First Aid Administered: | |
Medical Attention Required: | |
Medical Facility Visited: |
Description of Property Damage: | Minor damage to shelf corner |
Estimated Cost of Damage: |
List of immediate corrective actions: | The wet floor was cleaned immediately, and additional caution signs were placed. |
Signature of Reporting Employee:
[Your Name]
[Job Title]
[Month Day, Year]
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