Date and Time of Accident

Location (Area)

• Warehouse

• Workshop

• Production Floor

Reporter Name

Job Title/Role

Company Name

Phone number

Email

Name of Injured Employee

Incident Description

Provide a detailed description of the incident. Include events leading up to, during, and after the occurrence.

Type of Incident

• Equipment Failure

• Electrical Malfunction

• Operator Error

• Moving Parts Hazard

Witness Name 1

Phone number

Witness Name 2

Phone number

Upload Relevant Files

Type of Equipment Involved

• Forklift

• Conveyor Belt

• Power Tool

Condition of Equipment Before Incident

Were there any injuries?

• Yes

• No

Description of Injuries or Damages

Describe the type and severity of injuries. Specify who was injured and their condition.

Was medical attention provided?

Immediate Actions Taken

Describe actions taken to address the incident, such as shutting down equipment, repairs, or providing aid.

Was the incident reported to a supervisor?

• Yes

• No

Supervisor Name

Phone Number

Additional Comments

Include any further information, suggestions, or recommendations to prevent future occurrences.