Safety Incident Report

Safety Incident Report

Safety Incident

Please fill out thoroughly, this information needs to be recorded and kept on file.

Date

Submitter

Individual Involved

Witness

Project Leader

Job Name/#

What did happen?

Specific body part that was injured

Did the employee leave work after injury?

Select or enter value

Is the employee getting medical treatment?

If employee is seeking medical treatment, Ronnie/Steve, James and Sarah need to be notified.

What could have potentially happened?

Corrective Action taken or suggested correction?

Send me a copy of my responses

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