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Incident

This disciplinary report documents an accident involving an employee, including their personal information, details of the incident such as time and location, a description of any damages, contributing factors according to witness remarks, and corrective measures to be taken by the supervisor to prevent reoccurrence. The employee and supervisor signatures are also included at the bottom to acknowledge the report.

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Danielle Hirata
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170 views1 page

Incident

This disciplinary report documents an accident involving an employee, including their personal information, details of the incident such as time and location, a description of any damages, contributing factors according to witness remarks, and corrective measures to be taken by the supervisor to prevent reoccurrence. The employee and supervisor signatures are also included at the bottom to acknowledge the report.

Uploaded by

Danielle Hirata
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
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DISCIPLINARY REPORT

EMPLOYEE INFORMATION ACCIDENT INFORMATION


NAME DATE
AGE TIME
CONACT # LOCATION
POSITION WITNESS

DESCRIBE WHAT HAPPENED IN DETAIL INCLUDING TIMES AND LOCATIONS

DESCRIBE ALL DAMAGE IN DETAIL INCLUDING ANY PART OF THE BODY/PROPERTY AFFECTED IF
APPLICABLE

DID YOU SEEK MEDICAL PROFESSIONAL? IF YES, PROVIDE NAME, ADDRESS AND CONTACT NO.

WHAT ARE THE CONTRIBUTING FACTORS FOR THE


REMARKS FROM WITNESSES
INCIDENT?

CORRECTIVE MEASURES: ACTIONS NEED TO BE DONE TO PREVENT REOCCURENCE (COMPLETED BY


SUPERVISOR)

EMPLOYEE REPORTING INCIDENT:


SIGNATURE DATE

SUPERVISOR
SIGNATURE DATE

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