To:____________________ |
Date of
Incident:___________________ |
|
Location of
Incident:________________ |
|
_________________________________ |
|
Map/sketch
on reverse side or attach |
From:_______________ |
Phone:_________ |
Time of Incident:_______ |
Nature of the incident: (xx all applicable boxes)
____Assaults or violent acts: ____ Type "1"____
Type "2" ____ Type "3" ____Other
____Preventative or warning report
____Bomb or terrorist type threat (special checklists attached Yes or No)
____Transportation accident
____Contacts with objects or equipment
____Falls
____Exposures
____Fires or explosions
____Other
Legal counsel advised
of incident
____Yes ____No |
EAP
advised
____Yes ____No |
Warning or
preventative measures
____ Yes ____ No |
|
Number of persons affected |
|
(For each person complete a report; however, to the
extent facts are
duplicative, any person's report may incorporate another person's report.)
|
Name of affected person(s): ________________________ |
Service date:______________ |
Position:__________________________ |
member of labor organization
____Yes ____No |
Supervisor: _______________________ |
has supervisor been notified ____Yes____No |
Family: ___________________________ |
has been notified
____Yes ____No |
Lost work time ____Yes ____No
Anticipated return to work ____
Third parties or non-employee involvement ____Yes ____No (include contractor and lease
employees, visitors, vendors, customers)
Nature of the incident
Briefly describe: (1) event(s); (2) witnesses with addresses and status included; (3)
location details; (4) equipment/weapon details; (5) weather; (6) other records of the
incident (e.g., police report, recordings, videos); (7) the ability to observe and
reliability of witnesses; (8) were the parties possibly impaired because of illness,
injury, drugs or alcohol (were tests taken to verify same ____Yes ____No); (9) parties
notified internally (employee relations, medical, legal, operations, etc.) and externally
(police, fire, ambulance, EAP, family, etc.)
Previous or related incidents of this type ____Yes ____No
or by this person ____Yes ____No
Preventative steps ____Yes____No
OSHA log or other OSHA action required ____Yes ____ No
Incident Response Team: