Health & Safety Incident Report Slip

Please complete all sections of this slip and submit it to the administrative office.

Incident Details:

Employee Name:	[Name]
Employee ID:
Supervisor Name:
Department:
Job Title:

Description of Incident:

[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

Nature of Injury:	[Laceration]
Body Part(s) Affected:

First Aid Provided:

Medical Treatment Required:

Witness Information:

Witness 1 Name:	[Name]
Contact Information:
Witness 2 Name:
Contact Information:

Supervisor Comments:

Corrective Actions Taken:

Recommendations for Preventing Recurrence:

Report Completed By:

[Your Name]

[Job Title]

[Date]

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