Workplace Incident Assessment Form
Workplace Incident Assessment Form
This form is provided by [Your Company Name] for the reporting and assessment of workplace incidents. It is to be completed by the employee involved in or witnessing the incident. The information provided will be used to evaluate the incident and implement measures to prevent future occurrences.
Instructions:
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Complete all sections of the form as accurately and thoroughly as possible.
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Submit the completed form to your supervisor or the designated safety officer within 24 hours of the incident.
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For any inquiries, contact [Your Company Phone Number] or email [Your Company Email].
Section 1: Employee Information
|
Aspect |
Details/Response |
|
Name: |
[Your Name] |
|
Job Title: |
[Job Title] |
|
Department: |
[Department] |
|
Contact Number: |
[Your User Phone] |
|
Email: |
[Your Email Address] |
Section 2: Incident Details
|
Aspect |
Details/Response |
|
Date of Incident: |
[Month Day Year] |
|
Time of Incident: |
[Time] |
|
Location of Incident: |
[Specific Location within Workplace] |
|
Description of Incident: |
[Detailed Description of What Happened] |
Section 3: Nature of Incident
|
Aspect |
Details/Response |
|
Type of Incident: |
(e.g., Injury, Property Damage, Near Miss) |
|
Cause of Incident: |
[Possible Cause(s) of Incident] |
|
Injury Details: |
[If applicable, describe the injury incurred] |
|
Damage Details: |
[If applicable, describe the property damage] |
Section 4: Witnesses and Immediate Action
|
Aspect |
Details/Response |
|
Witness(es) Names |
[Names of Witnesses, if any] |
|
Action Taken Post-Incident |
[Immediate Response Actions Taken] |
|
Reported to Supervisor |
[Yes/No, Supervisor's Name] |
Section 5: Additional Information
|
Aspect |
Details/Response |
|
Additional Comments |
[Any further information or comments] |
|
Supporting Documents |
[Attach any relevant photos, videos, or documents] |
Section 6: Employee Acknowledgment
I, [Your Name], hereby confirm that the information provided above is accurate to the best of my knowledge.
Employee’s Signature: ________________________
Date: _____________
For Office Use Only
|
Aspect |
Details/Response |
|
Received By: |
[Name of Receiver] |
|
Date Received: |
[Date] |
|
Follow-Up Actions: |
[Description of any follow-up actions to be taken] |
|
Completed By: |
[Name of Person Completing Form] |
|
Date Completed: |
[Date Completed] |
Contact Information:
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[Your Company Phone Number]
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[Your Company Email]
-
[Your Company Website]
-
[Your Social Media]
This form is part of [Your Company Name]'s commitment to maintaining a safe and healthy work environment. All information provided will be treated confidentially and used solely for workplace safety and incident management.
