WORKPLACE INCIDENT REPORT

Employee / person involved: __________________________
Job / department: ____________________________________
Date and time: _______________________________________
Exact location: ______________________________________

Type of incident: Injury / Near Miss / Property / Other
Description: _________________________________________
_________________________________________________

Contributing conditions: _____________________________
Immediate corrective action: _________________________
Further investigation needed: Yes / No
Recommended follow-up: ______________________________

Supervisor: __________________ Signature: ____________