Date

Incident Location

Reporter's Name

Reporter's Email

Please provide your email address.

Reporter's Phone Number

Role

• Employee

• Supervisor

• Visitor

Type of Violation

• Failure to Follow Safety Procedures

• Use of Unauthorized Equipment

• Neglect of Personal Protective Equipment (PPE)

• Hazardous Behavior

Detailed Account of Violation

Provide a clear explanation of what occurred, including the rules or policies violated.

Was there an immediate danger to individuals?

Were any injuries or damages reported?

Immediate Actions Taken

Describe actions taken to address the violation, such as stopping the activity, notifying a supervisor, or providing corrective instructions.

Relevant Files or Documents