Health %2526 Safety Incident Report Form
Health & Safety Incident Report Form
Incident Report Number:
Date and Time of Incident
Location of Incident
Type of Incident
Description of Incident
Injuries Sustained
Property Damage
Persons Involved
Name of Injured Person
Job Title
Phone number
Witness
Immediate Actions Taken
Action Taken
Reported to Supervisor?
Medical Attention Required?
Follow-Up Actions
Preventive Measures
Training Required
Reported By:
Job Title:
Date:
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