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Incident Report Checklist

This procedure is a comprehensive incident reporting that can help your business understand what is going wrong or could go wrong regarding workplace safety. With these insights, an organisation can fix a health and safety issue before it becomes a bigger problem that can cause serious harm or damage to employees or property
MaintainX
10/24/2021

Incident Report Checklist

This procedure is a comprehensive incident reporting that can help your business understand what is going wrong or could go wrong regarding workplace safety. With these insights, an organisation can fix a health and safety issue before it becomes a bigger problem that can cause serious harm or damage to employees or property

    This form must be completed within 24 hours of the Supervisor learning of the incident

    THIS SECTION TO BE COMPLETED BY THE EMPLOYEE

    Who was hurt?

    Last name:

    First Name:

    Phone or Extension:

    Job Title:

    Department:

    Supervisor:

    Date & Time of Incident:

    Date Reported:

    Type of Incident:

    Description of Incident:

    *If this was a SLIP, describe footwear:

    Witnesses to the incident: (names and phone numbers)

    What was the injury (indicate what part of the body):

    Did you see a medical professional?

    If YES, please provide name, address and phone number:

    Treatment of Injury:

    THIS SECTION TO BE COMPLETED BY THE SUPERVISOR

    Contributing Factors: What conditions contributed to the incident?

    Explanation of contributing factors:

    Details of property damage (if any):

    To your knowledge, has the employee had a previous similar injury or has this similar hazard been reported before?

    • Yes
    • No
    • N / A

    Corrective Measures: Actions taken to prevent a reoccurrence (more than one item may apply):

    Explanation of corrective measures:

    Signature of Employee Reporting Incident:

    Click here to sign

    Date:

    Signature of Supervisor:

    Click here to sign

    Date:

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