INCIDENT REPORT
Involved Employee's Name:
*
First Name
Last Name
Morrow Steel Job Name:
*
Please Select
2110 Bausch Health WH
Date of Incident:
*
-
Month
-
Day
Year
Date
Involved Employee's Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Involved Employee's Phone Number:
Please enter a valid phone number.
Format: (000) 000-0000.
Involved Employee's Hire Date:
-
Month
-
Day
Year
Date
Involved Employee's Book #:
Involved Employee's Job Title:
Involved Employee's Experience (Years):
Supervisors Name:
*
First Name
Last Name
Supervisor's Email:
*
example@example.com
Injuries:
*
Yes
No
Medical Treatment Refused:
*
Yes
No
Description of Incident:
Involved Employee's Signature:
*
To Be Completed by Management Form
Date & Time of Incident:
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Date Reported:
-
Month
-
Day
Year
Date
Type of Incident
Fire
Near Miss
Property Damage
Report Only - Medical Treatment Refused
Medical Treatment
First Aid
Lost time
Fatality
Location of Incident:
If Injured, describe in detail:
Be sure to include, Injury, Cause, body part affected
What actions have been taken to prevent recurrence?
Upload Files
Morrow Steel Representative Signature:
*
Submit
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