Cleaning Services Employee Incident Report Form
Instructions: Please fill out this form thoroughly and accurately in relation to any incident encountered during your duties. Your report helps us improve safety and prevent future incidents.
Employee Name: | |
Location of Incident: | |
Date of Incident: | |
Time of Incident: | |
Description of Incident
During routine cleaning duties at the client's office building, while mopping the corridor on the second floor, I noticed a wet floor sign had been knocked over and was not visible to passersby. As I approached to pick it up and reposition it, I slipped on the wet surface, causing me to fall backward and hit my head on the floor. The floor had recently been mopped by another cleaning staff member, but no caution tape or warning signs were placed to indicate the wet area. |
Any Injuries
Sustained a minor concussion and a bruise on the back of the head. Immediate pain and dizziness were experienced post-fall. No visible cuts but significant discomfort noted. |
Actions Taken After Incident
Following the incident, immediate assistance was provided by colleagues, including first aid with ice for the injury. The employee received medical attention for a minor concussion at an urgent care facility, where they were advised to monitor symptoms and possibly seek further medical advice. The incident was formally reported to the safety coordinator and supervisor, highlighting the need for visible and secure wet floor signs, and suggesting the introduction of additional safety measures like caution tape. A follow-up meeting was scheduled with the safety coordinator to ensure the incident was properly addressed and to discuss updates to safety protocols to prevent similar incidents in the future. |
After completing this form, please submit it to your supervisor or the safety coordinator. Let's work together to create a safer work environment.
Note: All reports will be handled with confidentiality and professionalism.
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