This form must be completed within 24 hours of the Supervisor learning of the incident
Result of Injury?
Was first aid administered at Aero or was the team member sent to the hospital/clinic ?
Please select the type of injury that occurred.
Was adequate PPE worn?
First name of injured team member
Last name of injured team member
Phone # of injured team member
Date & Time of Incident:
Describe the Incident / Describe any first aid provided :
If injured team member was sent for medical treatment, please provide the name and phone number for the facility:
THIS SECTION TO BE COMPLETED BY THE SUPERVISOR
First & Last Name:
Full Name of the Supervisor filling this form out
Contributing Factors: What conditions contributed to the incident?
Explanation of contributing factors:
Details of property damage (if any):
To your knowledge, has the team member had a previous similar injury before?
Explanation of corrective measures:
Attach pictures of incident if any
Add or drag pictures
Signature of Supervisor:
Click here to sign
Source: Aero Industires (Community Member)