Employee Safety Incident Report printable pdf download

Employee Safety Incident Report

PURPOSE: This form is to be used by employees to document their workplace illnesses and injuries.

INSTRUCTIONS:



For serious life or limb threatening injuries, call 911 or go to the nearest Emergency Room, and

report the injury after the situation has stabilized.



Promptly report all workplace injuries & illnesses to your supervisor AND the Human Re-

source Manager—even if first aid or medical care is not required.



Complete this form, and give it to Human Resources within 1 business day of the incident.



If a consumer was involved, (1) report the incident to your supervisor, (2) do not identify the con-

sumer by name in this report and (3) complete a separate consumer incident report.



If medical attention is required, Human Resources will arrange care through Concentra; as a gen-

eral rule, you should not [initially] see your own doctor for work-related injuries.

EMPLOYEE INFORMATION

Name:

Job Title:

Date of Birth:

Hire Date:

INCIDENT INFORMATION

Date of Incident:

Time of Incident:

Shift Start Time:

Location of Incident:

INCIDENT DESCRIPTION

What were you doing just before the incident occurred?

What happened?

What is the nature of the injury or illness?

What object or substance directly harmed you?

Employee Safety Incident Report