Injury Emergency Report Slip
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]
