Statement of Facts
Document the facts of the incident and complete the closeout process. This form is first completed by the Regional Safety Manager, then routed to the employee for comments and acknowledgment.
Employee Name
*
Employee Email
*
example@example.com
Date of Incident
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Region
*
Regional Safety Manager
*
Regional Safety Manager Email
*
example@example.com
Supervisor
*
Incident Classification
*
Please Select
Choose an item.
Injury - First Aid
Injury - Recordable
Lost Equipment
MVA - Preventable
MVA - Non-Preventable
Property Damage
Theft
Statement of Facts (Verified Facts Only)
*
Submit
Should be Empty: