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 |