Incident Report Checklist

Audit verification
Mention the date
Provide Signature
First Section
Mention date of the incident
Mention time of the incident
Mention date and time of the incident reported
Mention time of the incident reported
Whom was the incident reported to?
Mention the location of incident
Mention the Supervisor's name
Mention Supervisor's phone number
If witness(es) was present mention the name(s)
People associated
Mention the name of the person(1) involved
Mention the phone
Mention the sex
Mention the age
Mention the job title
Mention the time on job (yrs. & mos.)
Mention job status
Mention employee disposition status
Was any medication prescribed?
Type of Injury
Provide the name if any first-aid or medical treatment administered.
Mark if Property Damage:
Upload the photo of damage
What kind of Property was damaged
Upload the photo of damage
Mention the estimated cost of damage
Mention the Vehicle Id
Mention the Make/Model
Provide detailed description of the incident.(include environmental conditions at time of incident)
Upload environmental photo
What are the underlying causes/factors for the injury?
Upload image of the contributing factors
What are the corrective action (mention the detail description of action and persons responsible for action)
Select the nature of the potential for severity.
What might have happened potentially?
What is the chance of reoccurrence?
Describe the nature of injury

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