Safety Incident Report Safety Incident Report Online Form Name of person filling out report First Last Type of Incident Near Miss Safety Incident with Personal Injury Safety Incident with Property or Environmental Damage Date of Incident MM slash DD slash YYYY Time of Incident Hours : Minutes AM PM AM/PM Location of Incident Job Number Supervisor Name, Title/Position & Contact NumberEmployee(s) Name, Title/Position & Phone NumberDescription of IncidentWas anyone injured? Yes No If Yes, Please Describe Injury in DetailWas medical attention provided? Yes No Refused If Yes, Please provide Name(s) and contact info of physician/healthcare professional who provided medical attention.Name and address of facility where medical attention was provided (if other than job site)Was the employee admitted to the hospital overnight? Yes No Is employee able to perform regularly assigned work duties? Yes No If employee requires modified duty or leave of absence, provide those plans and the estimated return to work date.Did property or environmental damage occur? Yes No If Yes, Please describe the damage in detail.Were there witnesses to the incident? Yes No If Yes, Please provide Name(s) and contact info of witnesses.Additional Comments
