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]