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Incident Report

This document is an incident report form used to document accidents, injuries, incidents, illnesses, and observations. It requires details such as the date, time, location, and specifics about the injured person and the event. The completed form must be submitted to Operations Management or Admin within 12 hours of the incident.

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Zeeshan Ali
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11 views1 page

Incident Report

This document is an incident report form used to document accidents, injuries, incidents, illnesses, and observations. It requires details such as the date, time, location, and specifics about the injured person and the event. The completed form must be submitted to Operations Management or Admin within 12 hours of the incident.

Uploaded by

Zeeshan Ali
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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DEX-HSSE-FM-02-01

INCIDENT REPORT
Use this form to report any accident, injury, incident, illness.
Return completed form to Operations Management / Admin within 12 hours of the incident.

This is documenting:

Injury First Aid Incident Illness Observation Other:____________

Incident Details:

Incident Date: __________________ Incident Time: __________________ Incident Location: _________________

Injured Person Details:

Name: ______________________________________________ Contact#: ________________________________

Address: __________________________________________________________ Employee ID: ________________

Injury Details: __________________________________________________________________________________

Taken to hospital? Yes No

Details of the Event: (Please use the back of the page if required)

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

Was event caused by an unsafe act? Or any unsafe condition? Or any other? Root cause? (Please explain)

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

Prepared By: Approved By:

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