Incident Notification
Date of Report
Date of Incident
Operating Department
Production
Sales
Admin/Office
Type of Incident
Injury
Damage
Vehicle
Fire
Information & Documentation
Near Miss
Reputation
Entity Involved
Tuff Shed employee
Contractor
Type of Notification
First Notification of Incident
In Progress
Final Report
Information Only
Good Catch
Store Number
Type of Injury
N/A
First Aid
Recordable
Lost Time
Fatality
Time of Incident
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
05
10
15
20
25
30
35
40
45
50
55
Minutes
AM
PM
AM/PM Option
Person Reporting Incident
First Name
Last Name
Person Reporting Email Address
example@example.com
Person(s) Involved
Supervisor
First Name
Last Name
What Happened?
Chronological Order of Events
Witness/s (Click [Save] to add additional witness/s)
Upload Witness Statements
Browse Files
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of
Capture/Upload Photo(s)
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of
Upload Incident Report
Browse Files
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of
Upload Other Files
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of
Investigation
Investigation Leader
First Name
Last Name
Investigation Team
Name of Event
Causal Chart
Root Cause(s)
Corrective Action Item(s)
For Office Use Only
Submit
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