Incident Report Checklist

Who was hurt?

• Employee

• Visitor

• Contractor

• Other

Last name:

First Name:

Phone or Extension:

Job Title:

Department:

Supervisor:

Date & Time of Incident:

Date Reported:

Type of Incident:

• Slip, trip or fall

• Struck by / against object

• Over exertion

• Repetitive strain

• Electrical contact

• Exposure to hazardous material

• Other (describe)

Description of Incident:

*If this was a SLIP, describe footwear:

Witnesses to the incident: (names and phone numbers)

What was the injury (indicate what part of the body):

Did you see a medical professional?

• Yes

• No

If YES, please provide name, address and phone number:

Treatment of Injury:

• First Aid

• Family Doctor

• Walk-in Clinic

• Emergency Room

• Other (describe)

Contributing Factors: What conditions contributed to the incident?

• Unsafe equipment

• Insufficient training

• □ Failure to use PPE

• Inadequate illumination

• Improper position/posture

• Operating without authority

• Not or improperly guarded

• Insufficient care

• Failure to lockout

• Hazardous environment

• Infraction or unsafe practice

• Other (Explain)

Explanation of contributing factors:

Details of property damage (if any):

To your knowledge, has the employee had a previous similar injury or has this similar hazard been reported before?

• Yes
• No
• N / A

Corrective Measures: Actions taken to prevent a reoccurrence (more than one item may apply):

• Request job safety analysis

• Improve work procedure

• Repair or replace equipment

• On-the-job training

• Check with manufacturer

• Install safety guard/device

• Perform housekeeping

• Re-training of person(s)

• Reassignment of person

• Review PPE

• Constructive Discipline

• Other (Explain)

Explanation of corrective measures:

Signature of Employee Reporting Incident:

Date:

Signature of Supervisor:

Date: