Free Incident Report Template
Incident Report
I. Incident Details
|
Field |
Description |
|---|---|
|
Date |
May 15, 2054 |
|
Time |
10:30 AM |
|
Location |
Main warehouse |
|
Incident Type |
Slip and fall |
|
Description |
The employee slipped on a wet floor near the loading dock, resulting in a fall and minor injuries. |
|
Involved Parties |
Neal Knight (Injured Employee), [YOUR NAME] (Supervisor), Mike Jones (Witness) |
|
Witnesses |
Mike Jones (Contact: mike@email.com) |
II. Injury Details (If Applicable)
|
Field |
Description |
|---|---|
|
Injured Party |
Neal Knight |
|
Nature of Injury |
Minor abrasions and bruising |
|
Severity |
Minor |
|
Treatment Provided |
Cleaned and bandaged on-site, no further medical attention is required |
|
Medical Attention |
None |
III. Actions Taken
|
Action Taken |
Description |
|---|---|
|
Immediate Response |
The employee was assisted to a safe area and the area was cordoned off for cleaning. |
|
Investigation |
The supervisor interviewed the employee, reviewed CCTV footage, and inspected the area for hazards. |
|
Corrective Measures |
Wet floor signs were placed and a reminder email was sent to all employees about safety procedures. |
|
Follow-up |
Scheduled additional training on workplace safety for all warehouse staff. |
IV. Recommendations
|
Recommendation |
Description |
|---|---|
|
Safety Improvements |
Consider installing anti-slip mats in high-risk areas and increase the frequency of floor inspections. |
|
Training Needs |
Conduct regular safety training sessions focusing on slip and fall prevention. |
|
Policy Review |
Review and update the company's safety policies regarding floor maintenance and signage. |
V. Witness Statements (If Applicable)
|
Witness Name |
Contact Information |
Statement |
|---|---|---|
|
Mike Jones |
mike@email.com |
"I saw Neal slip on the wet floor near the loading dock. It had just been cleaned, but there were no warning signs." |
VI. Supervisor's Approval
I, [YOUR NAME], hereby approve this workplace incident report and confirm that the information provided is accurate to the best of my knowledge.
[YOUR NAME]
Company Supervisor, [YOUR COMPANY NAME]
Date: [DATE SIGNED]
