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Employee’s Report Of Incident
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Incident Report
EMPLOYEE’S REPORT OF INCIDENT
Employee Name
*
Date Reported
*
MM slash DD slash YYYY
Department
*
Job Classification
*
Time on Job
*
Date of Incident
*
MM slash DD slash YYYY
Time of Incident
*
Shift
*
Task Being Performed
*
Was The Assignment Regular or Irregular?
*
Exact Location of Incident
*
Describe the Incident
*
Check one:
*
Check one:
Mechanical or other safeguards provided and used
Mechanical or other safeguards provided and not used
Mechanical or other safeguards not required
Nature of Injury?
*
Part of Body Injured?
*
Did You Receive Medical Attention?
*
Did You Receive Medical Attention?
Yes
No
If so, where?
Check One About Your Medical Attention
*
Check One About Your Medical Attention
No outside medical attention required
Sent to doctor/nurse and return with continued work
Doctor/nurse sent home for balance of shift
Other
How Long After The Injury Did You Report It?
*
List of Witnesses
*
Corrective Action to Prevent Recurrence
*
Your Virtual Signature
*
Date Filling Out This Form
*
MM slash DD slash YYYY
Phone
This field is for validation purposes and should be left unchanged.
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