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Safety Incident Report

This accident/incident report form collects information about events that resulted in injury or property damage. It records the date, time, location and description of the incident, witnesses, whether it was caused by an unsafe act or condition, and details of any injuries or medical treatment required. The person completing the form provides their name and signs and dates the document.

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Usama Hasni
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236 views

Safety Incident Report

This accident/incident report form collects information about events that resulted in injury or property damage. It records the date, time, location and description of the incident, witnesses, whether it was caused by an unsafe act or condition, and details of any injuries or medical treatment required. The person completing the form provides their name and signs and dates the document.

Uploaded by

Usama Hasni
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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Accident / Incident Report Form

Date of Incident_________________ Time__________ AM/PM

Person Completing Report: _________________ Location: ___________________________________

Event Details:

Date of Event: ____________________ Location of Event: ___________________________________

Time of Event: ____________________ Witnesses: __________________________________________

Description of Event: ___________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________
(if more space is required please use back of the sheet)

Was event / injury caused by an unsafe act (activity or movement) or an unsafe condition (Machinery or
weather)? Please Explain: ________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

TO BE COMPLETED ONLY IF LOST TIME/ INJURY OR FIRST AID WAS REQUIRED


Type of Injury sustained:

Cause of lost time/ injury or


first aid:
Was medical treatment Yes ___________ No___________
necessary? If Yes, Name of Hospital / physician____________________________________________________________________________

Signature of Safety Officer: _______________________ Date: _____________

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