Incident and Accident Report Form
Date:
Time:
Location:
Type of incident: (Accident, injury, near miss, property damage, etc.)
Description of incident: (Please provide a detailed description of the incident, including what happened, when it happened, and who was involved.)
Injuries: (Please list all injuries, including severity.)
Property damage: (Please describe any property damage, including the type and extent of damage.)
Witnesses: (Please list the names and contact information of any witnesses.)
Actions taken: (Please describe any actions that were taken immediately after the incident, such as providing first aid, evacuating the area, or securing the scene.)
Root cause analysis: (Please provide a root cause analysis of the incident, if possible.)
Corrective actions: (Please describe any corrective actions that will be taken to prevent similar incidents from happening in the future.)
Signature of employee reporting incident:
Signature of supervisor:
This form can be used to report a variety of incidents and accidents, including:
* Accidents that result in injury or death
* Near misses (accidents that were narrowly avoided)
* Property damage
* Equipment failures
* Spills and leaks
* Exposures to hazardous materials
* Security breaches
By reporting incidents and accidents, companies can identify and address hazards in their workplaces. This helps to prevent future accidents and injuries.
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