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Incident Report Form: Instructions: Please Complete This Form in Its Entirety Within 12 Hours of The Incident

This incident report form requests information about an incident including the type, date, time, location, those involved, witnesses, a description of what happened, and whether it was caused by an unsafe act or condition. The form is to be completed within 12 hours of the incident by the person reporting it and signed by both the employee and supervisor.

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Eiza Laxa
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33 views

Incident Report Form: Instructions: Please Complete This Form in Its Entirety Within 12 Hours of The Incident

This incident report form requests information about an incident including the type, date, time, location, those involved, witnesses, a description of what happened, and whether it was caused by an unsafe act or condition. The form is to be completed within 12 hours of the incident by the person reporting it and signed by both the employee and supervisor.

Uploaded by

Eiza Laxa
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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INCIDENT #

Incident Report Form


Instructions: Please complete this form in its entirety within 12 hours of the incident.

Type of Incident:
□
□ Injury □ Property Damage
□ Illness □ Theft
□ Accident
□ Other
Please explain:

Date of Incident: Time of Incident:


Location of Incident:
Reported by (Name and Position):

NAME AND CONTACT DETAILS OF PERSON/S INVOLVED:


1.
2.
3.
NAME AND CONTACT DETAILS OF WITNESS/ES:
1.
2.
3.
Incident description including any events leading to or immediately following the incident:

Was the incident caused by an unsafe act (activity, movement or an unsafe condition (machinery or weather))?
Employee Signature and Date Supervisor Signature and Date

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