Injury Emergency Report Slip

Incident Details

Date & Time of Incident	Location of Incident	Reported By
[Month Day, Year]	Warehouse Section C	[Eric Smith]

Nature of Incident:

• Slip/Trip/Fall

• Machinery/Equipment Accident

• Exposure to Hazardous Material

• Struck by Object

• Other:                               

Brief Description of Incident:

A steel beam dislodged from its storage position on the upper rack, striking [Nathan Banes] on the shoulder.

Victim Details

Name of Victim	Employee ID	Department	Contact Number
[Nathan Banes]	102345	Logistics	[555-154-4589]

Nature of Injury:

• Bruising

• Fracture

• Laceration

• Burn

• Other:                               

Specific Area of Injury:

Right shoulder and upper arm

First Aid Measures

First Aid Provided	First Aider	Time Administered
Immobilization of Arm	[Luke Hyden]	10:50 AM

Medical Response

Ambulance Called	Hospital Notified	Estimated Time of Arrival
Yes	Local Hospital	11:10 AM

Report Prepared by: [Your Name]

Signature: ________________

Date: [Month Day, Year]

Supervisor's Signature: __________

Date: [Month Day, Year]

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