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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
DSV Solutions
06/23/2022

Incident Report Checklist

21 steps
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

  • Last name:

  • First Name:

  • Job Title:

  • Department:

  • Employee involved with the incident :

  • Date & Time of Incident:

  • Date Reported:

  • Description of Incident:

  • Witnesses to the incident: (names and phone numbers)

  • Describe if there is personal 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
    • Explanation of corrective measures:

    • Attach pictures of incident if any

      Add or drag pictures
    • Signature of Supervisor:

      Click here to sign
    • Date:

    Source: DSV Solutions (Community Member)

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