Workplace Incident Evaluation Form
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] |
Instructions:
Complete this form accurately to document workplace incidents, aiding in compliance and safety enhancement. Follow the guidelines provided.
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:
|
Preventive Measures:
|
Corrective Actions Taken |
Immediate Actions:
| Long-Term Actions:
|
Supervisor/Manager Comments |
|
Supervisor/Manager Name: [Your Name]
Date: [Insert Date]
Health & Safety Templates @ Template.net
