Incident Report

AN Incident is a potential hazard due to unsafe working conditions, unsafe employee work habits, improper use of equipment or use of malfunctioning equipment that have the potential to cause work related injuries and contribute to work related incidents. Please complete this form to report these Incident situations.

Company*
Employee*
First Last
Location*
Incident Date*
MM
DD
YYYY
Incident Time*

: HH

MM
Please check all appropriate conditions:*
- Unsafe Act
- Unsafe Condition
- Unsafe Equipment
- Unsafe use of Equipment
Describe the Incident
Causes: (primary & contributing)
Corrective Action Taken:
Signature*
Date
Date Format: MM slash DD slash YYYY
Name
This field is for validation purposes and should be left unchanged.

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