Employee Incident Report

Note to Manager: If you are completing this for the employee please read each question with the employee and ensure each item is answered fully. Record answers using the exact response of the employee (eg: "I looked to my left and did not see the obstacle").

You must read the following statement to the employee before starting:

This interview acts as your statement of events following an incident which occurred while employed at Shippers Supply Inc. Please be as thorough as possible when giving your responses. Knowingly providing false information will result disciplinary action up to an including termination.

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* 1. Employee Name (Full Name)

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* 2. Employee Address

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Email Address

Phone Number

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* 3. Date of incident

Date / Time

Date

Time

AM/PM

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* 4. Type of incident

Injury

Property Damage

Near miss/other

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* 5. Where exactly did the incident occur? (location number, aisle, etc.)

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* 6. What were you doing just before the incident?

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* 7. Please provide a step-by-step statement using as much detail as possible to describe what happened

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* 8. What did you do right after the incident?

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* 9. What do you feel was the cause of the incident? What do you think could have been done to prevent the incident?

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* 10. Was anyone else involved?

Yes

If yes, who?

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* 11. Were there witnesses?

Yes

If yes, who?

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* 12. Was there equipment involved?

Yes

If yes, what equipment?

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* 13. Was there property damage?

Yes

If yes, please describe

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* 14. Were you injured?

Yes

If yes, please describe how (sprain, strain, struck by, etc.) and specific body part injured (right elbow, lower back, etc)

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* 15. Will you seek medical treatment? (If yes, please ensure employee speaks with HR to obtain WC Policy number)

Yes

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* 16. Were you required to wear PPE or fall protection at the time of the incident?

Yes

If yes, were you wearing equipment at time of injury?

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* 17. Additional information/comments (please use this space to share any additional information you feel may be pertinent to this incident)

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* 18. What ideas do you have that could have been done to prevent the incident or future incidents?

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* 19. Name and Title of Person Completing this form

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* 20. I understand that if I receive medical attention I will promptly submit all work restrictions to HR.

Yes