1. Name
|
Phone #
|
Exact
Time
|
Department
|
Occupation
|
3.
Address
|
City
|
Zip
|
Other
Information |
5. Date
First
Reported
|
|
6. Time
& Date
Accident/Damage
Occurred
|
Day of
Week |
Exact
Time
|
AM or PM |
|
7.
Nature
of
Injury:
|
|
8. Part
of Body
Injured |
|
9.
Degree
of
Injury
|
|
10.
Nature
of
Damage: |
|
11.
Cause of
Damage |
|
12. How
Did
Accident/Damage
Happen? |
13.
Location
of
Incident
(be
specific)
|
14.
Activity
of
Persons
(be
specific)
|
15.Other
Activity
|
16. Who
Was
in
Supervision
|
|
17. Who
Notified |
18.
Safety
Issues |
|
19.
Unsafe
Mechanical/Physical
Condition
|
20.
Unsafe
Personal
Factor
|
|
21.
Corrective
Action
Taken or
Recommended:
|
|
WHO:
|
|
WHAT:
|
|
22.
Description
(Give a
word
picture
of the
accident,
who,
what,
when,
why, and
how) |
|
WHO:
|
|
WHAT:
|
|
WHEN:
|
|
WHERE:
|
|
WHY:
. |
|
Witnesses:
|
23.
Employee's
Signature
|
Date:
|
24.
Report
Prepared
by:
|
Title
Date |
25.
Administrator's
Signature
|
Title |
Date |
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