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Incident Definitions
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Injury - physical harm or damage has occurred to a person, regardless of how minor (e.g. First Aid type injury)
Illness - a person has a recognized health condition, sickness, disease (e.g. skin rash)
Near Miss- any unplanned event that could have, but did not result in damage or injury, but still interrupted the normal, expected flow of a job or task
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Incident:
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Preparer's Name:
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Date Reported to Manager:
(MM/DD/YY)
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Incident Type:
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Date of Incident:(MM/DD/YY)
Time:
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Affected Employee Name:
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Employee Type:
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Work Related:
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Time with Company:
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Shift:
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Day of Week:
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Site Location:
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Department/Area:
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Exact Location (be specific):
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Source of Incident:
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Body Parts(s):
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Nature of Loss (if injury/illness):
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Unsafe Act/Condition(s):
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If Yes:
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Medical Treatment:
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Impact of Incident:
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Witnesses:
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If yes, Name:
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| Description of Incident: |
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| Containment/Interim Corrective Action Identified/Completed: |
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