Name of person injured or affected in the incident
Your answer
Job Title (if applicable)
Your answer
Birth Date
Birthday of injured or affected person
MM
/
DD
/
YYYY
Phone Number *
Phone Number of injured or affected person
Your answer
Email Address of injured or affected person *
Email address of injured or affected person
Your answer
Description of Incident
Type of incident *
Required
Pre-incident *
Your answer
Incident Description *
Detailed description of incident, including identification of any unsafe conditions, acts or procedures which contributed in any manner to the incident .
Your answer
Weather Conditions
Wind and temperature if applicable
Your answer
Police *
Were the police contacted?
Police Case Number
If police were contacted, what is the case number
Your answer
Ambulance *
Was the ambulance called?
First Aid *
Was first aid administered?
Injuries and treatment *
Detailed description of injuries and treatment.
Your answer
First Aid attendant *
Name and contact information for the person who administered First Aid
Your answer
Witnesses *
Name and contact information of at least two witnesses to the incident.
Your answer
Damage *
Detailed description of damage to property or equipment (if any)
Your answer
Action taken *
Your answer
Corrective Action *
Recommended corrective actions to prevent similar incidents
Your answer
Follow-up
Description of follow-up if applicable
Equipment Damage Resolved
Date of resolution (if applicable)
MM
/
DD
/
YYYY
Management Action Taken
Date of action taken (if applicable)
Your answer
Notes
Any additional information you find relevant
Your answer
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