Workplace Incident Survey

This survey aims to gather valuable insights into incidents, empowering us to improve safety measures continuously. Your honest and confidential feedback will contribute to creating a safer and more secure working environment for all.

Incident Details

Type of Incident:	Property Damage
Date and Time:
Location:
Description of the Incident:

Witnesses

Witness Name:	Contact Information:
[Your Name]	[Your Number] / [Your Email]

Contributing Factors

1. Human Factors

   • Training

   • Communication

   • Fatigue

   • Other: ___________________

2. Equipment/Tool Issues

   • Malfunction

   • Lack of Maintenance

   • Other: ____________________

3. Environmental Factor

   • Weather

   • Lighting

   • Other: ___________________

Safety Procedures and Training

1. Were employees involved adequately trained for the tasks?

   • Yes

   • No

2. Were established safety procedures followed?

   • Yes

   • No

3. How is safety information communicated within the organization?

   • Yes

   • No

Preventive Measures

Immediate Actions Taken

On the day of the incident, first aid was administered promptly, and the affected area was cordoned off for safety. The incident was reported to the supervisor, and an initial investigation was initiated to identify immediate causes.

Recommendations for preventing similar incidents:

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