Workplace Incident Evaluation Form
Workplace Incident Evaluation Form
|
Employee Name: [Peter Chen] |
Incident Report Number: [2023-001] |
|
Job Title: [Machine Operator] |
Contact Number: [(555) 555-5555] |
|
Location: [Main Manufacturing Facility] |
Date of Incident: [12/01/2053] |
Instructions:
Complete this form accurately to document workplace incidents, aiding in compliance and safety enhancement. Follow the guidelines provided.
|
Incident Details |
|
|
Time of Incident: 09:30 AM |
Witnesses: 1. Andrea Oh 2. ____________________________ 3. ____________________________ |
|
Description of Incident: |
|
|
Injury/Illness Details (if applicable) |
||||
|
Nature of Injury/Illness: |
Medical Treatment Required:
|
|||
|
Name of Medical Provider: |
Hospital/Doctor Contact: |
|||
|
Equipment/Tools Involved (if applicable) |
|
|
Equipment/Tool Name: |
Serial/ID Number: |
|
Condition of Equipment/Tool: |
|
|
Root Cause Analysis |
|
|
Immediate Cause: |
Underlying Causes: |
|
Preventive Measures: |
|
|
Corrective Actions Taken |
|
|
Immediate Actions: |
Long-Term Actions: |
|
Supervisor/Manager Comments |
|
|
|
Supervisor/Manager Name: [Your Name]
Date: [Insert Date]
