Health & Safety Incident Report Slip
Health & Safety Incident Report Slip
Please complete all sections of this slip and submit it to the administrative office.
Incident Details:
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Employee Name: |
[Name] |
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Employee ID: |
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Supervisor Name: |
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Department: |
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Job Title: |
Description of Incident:
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[Name] was operating the CNC machine when he accidentally dropped a heavy metal component, which caused a laceration on his left forearm. |
Injury/Illness Details
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Nature of Injury: |
[Laceration] |
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Body Part(s) Affected: |
First Aid Provided:
Medical Treatment Required:
Witness Information:
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Witness 1 Name: |
[Name] |
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Contact Information: |
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Witness 2 Name: |
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Contact Information: |
Supervisor Comments:
Corrective Actions Taken:
Recommendations for Preventing Recurrence:
Report Completed By:
[Your Name]
[Job Title]
[Date]
