Employee Name: [Peter Chen]

Incident Report Number: [2023-001]

Job Title: [Machine Operator]

Contact Number: [(555) 555-5555]

Location: [Main Manufacturing Facility]

Date of Incident: [12/01/2053]

Incident Details

Time of Incident: 09:30 AM

Witnesses:

1.  Andrea Oh

2. ____________________________

3. ____________________________

Description of Incident:

Injury/Illness Details (if applicable)

Nature of Injury/Illness:

Medical Treatment Required: 

Name of Medical Provider:

Hospital/Doctor Contact:

Equipment/Tools Involved (if applicable)

Equipment/Tool Name: 

Serial/ID Number: 

Condition of Equipment/Tool:

Root Cause Analysis

Immediate Cause: 

Underlying Causes:

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Corrective Actions Taken

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Long-Term Actions: 

Supervisor/Manager Comments