Incident Reporting
Company Name
*
Jobsite Name
Incident report documented by:
*
First Name
Last Name
Send Report to
example@example.com
Your Email
example@example.com
What are you Reporting
*
Near Miss
Property Damage
Injury or Illness
Date of Incident:
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Month
-
Day
Year
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Time of Incident
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Hour
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Minutes
AM
PM
AM/PM Option
Date Incident was Reported:
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Month
-
Day
Year
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Near Miss Failure
Equipment
Material
People
Other
Cause Factor(s):
Unsafe Act
Unsafe Condition of Area
Unsafe Condition of Equipment
Unsafe use of Equipment
Unsafe Process
Lack of Training
Other
People and Tasks Involved
Photo(s) of Potential Hazards
Browse Files
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of
Potential Hazard
Safety Suggestions to prevent a similar Incident:
Submit
Date of Incident
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Month
-
Day
Year
Date
Time of Incident
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:
Hour
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10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Date Incident was Reported
-
Month
-
Day
Year
Date
Property Damage Failure
Equipment
Material
People
Other
Cause Factor(s):
Unsafe Act
Unsafe Condition of Area
Unsafe Condition of Equipment
Unsafe use of Equipment
Unsafe Process
Lack of Training
Other
People and Tasks Involved
Select Image(s)
Browse Files
Cancel
of
Potential Hazard
Safety Suggestions to prevent a similar Incident:
Submit
Date and Time of Incident
-
Month
-
Day
Year
Date
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Date Incident was Reported
-
Month
-
Day
Year
Date
Full Name of Employee
First Name
Last Name
Injured Body Part:
Photo(s) of Injury
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of
Location where incident occurred:
Equipment used when incident occurred:
Description of incident:
Why did the Incident Happen?
Reason for Failure
Equipment
Material
People
Other
Unsafe workplace condition (Check all that apply)
Inadequate guard
Unguarded hazard
Safety device is defective
Tool or equipment defective
Workstation layout is hazardous
Unsafe lighting
Unsafe ventilation
Lack of needed personal protective equipment
Lack of appropriate equipment/tools
Unsafe clothing
No training or insufficient training
Other
Unsafe acts by employee: (Check all that apply)
Operating without permission
Operating at unsafe speed
Servicing equipment that has power to it
Making a safety device inoperative
Using defective equipment
Using equipment in an unapproved way
Unsafe lifting
Taking an unsafe position or posture
Distraction, teasing, horseplay
Failure to wear personal protective equipment
Failure to use the available equipment/tools
Other
Answer the "Why" 3 Times
1. Why did it happen? Ask Why?
2. Why did (1) happen? Ask Why again
3. Why did (2) happen? Ask Why again
Photo(s) of the Root Cause
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of
Type of Response
First Aid
Refuse Medical Attention
Clinic Visit
Hospital Visit
No Response Required
I understand that my employer has offered medical services to me and at this time I am refusing medical attention. I was informed that I may request medical attention should my condition worsen.
Employee Acknowledgement Signature
Witness Statement
Further Comments
Submit
Should be Empty: