Incident Report

Injury, Non-Injury, Incident Report

Name: 

Job Title

Date of Injury

Time

Date Reported

Time

Time Shift Begin

Number of Days Missed

Number of Days on Light Duty

DESCRIPTION OF INJURY/NON-INJURY, INCIDENT OR SAFETY CONDITION
Note: Police may attach a copy of the Police Report to provide information foir this section. Please write "See Attached Report" under the description and sign the bottom of the page. The Supervisor's Report still needs to be completed however.

Exact Location of Incident:

Describe all acts and resulting conditions in detail:

What active measures, or assistance (if any) did employee take?

Names/Addresses/Phone Numbers of individuals (including employees) involved or of witnesses:

"THE ABOVE INFORMATION IS TRUE THE THE BEST OF MY ABILITY."

Employee Name:

Date:



Security Measure