Free Blank Incident Field Report Template
Blank Incident Field Report
Prepared by: [Your Name]
Date: [Date]
I. Incident Details
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Date of Incident:
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Time of Incident:
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Location of Incident:
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Incident Reported By:
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Report Number (if applicable):
II. Persons Involved
A. Person(s) Involved
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Name:
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Role/Title:
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Contact Information:
B. Witness(es)
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Name:
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Role/Title:
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Contact Information:
III. Description of the Incident
On October 15, 2054, at 3:15 PM, an incident occurred in Warehouse 3 involving a forklift and a stack of pallets. Trace Durgan, the forklift operator, was unloading inventory when he accidentally collided with a stack of loose pallets. The impact caused several pallets to tip over and create a loud noise.
Immediate Reactions:
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Lyda Fadel, a nearby employee, alerted Trace Durgan to stop the forklift.
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Warehouse Supervisor Rocky Orn responded and ensured no serious injuries occurred. Trace Durgan sustained mild bruising to his arm and was given first aid.
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The area was secured, and the incident was reported to the Safety Officer, Johann Harvey.
IV. Immediate Actions Taken
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First aid administered: Trace Durgan received treatment for minor bruising on his arm, applied by Warehouse Supervisor Rocky Orn.
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Emergency services contacted: Although no serious injuries were reported, Paramedic Unit 12 was contacted as a precaution. They arrived at the scene within 10 minutes and confirmed the minor nature of the injury.
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Area secured for safety: The warehouse area around the incident was cordoned off to prevent further accidents, and employees were instructed to avoid the location until it was deemed safe.
V. Cause of the Incident
The primary cause of the incident appears to be poor stacking of pallets, which created an unstable condition. Additionally, the forklift’s speed may have contributed to the collision. An internal investigation is being conducted to determine whether the forklift was being operated within the safety guidelines and if there were any mechanical issues.
VI. Follow-up Actions
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Equipment repairs: The forklift involved in the incident will undergo a thorough inspection to ensure all safety mechanisms are functioning properly. Any necessary repairs will be completed by Mechanics Team A.
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Additional training for staff: All forklift operators, including Trace Durgan, will undergo refresher training on the safe handling of equipment and proper stacking practices. The training will be led by Safety Officer Alexis Fox and scheduled for October 25, 2054.
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Revising safety protocols: A review of current warehouse safety protocols will be conducted, with a focus on improving pallet stacking procedures and forklift operational guidelines.
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Implementing new safety measures: New safety barriers will be installed around stacks of pallets to prevent future collisions. Additionally, speed limits for forklift operation in the warehouse will be enforced more strictly, with a speed limit of 5 mph being established.
VII. Signatures
Incident Report Prepared By:
[Your Name]
[Date Signed]
Reviewed By:
Jolie Cassin
[Date Signed]
