Incident Tracking Form
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1Store Name/Location: ___________________________ Date: _____/______/______ Quarter: ________
Total Quarterly Hours Reported: _____________________________ Quarterly Hours for Minors: ______________________
Incident Tracking Form
The following tool is intended to collect some basic information about the occurrence of injury incidents that do not result in a worker’s compensation claim. To more
accurately assess the true impact of an injury prevention strategy, a more complete picture of the occurrence of injuries is needed. Most injuries that occur in the
workplace do not result in the need for workers’ compensation, but the event refl ects risk factors that may be addressed by an intervention aimed at reducing all injuries.
This information is for informational purposes only and will not be used for anything outside of this focused intervention project.
Check
One
Job Task
Body Part
Type of
Injury Event
Injury Source
Slip-
Treatment*
Briefl y describe how
Date
(Food prep,
Injured
Injury
(Slip, fall, lifting,
(hot object, oil,
Resistant
(band-aid, ice,
the injury happened
Under
18 yr
grill, counter,
(hand, arm,
(cut, burn,
burn over-
knife, fl oor,
shoes
other fi rst-aid,
18 yr
or over
etc.)
face, eye,
sprain, etc.)
exertion, etc)
ladder, etc.)
Y/N
doctor visit,
back, etc.)
hospital, none)
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