Name of person involved in incident
*
First Name
Last Name
Individual's Status
*
Job Title
*
Department
*
Manager's Name
*
First Name
Last Name
Manager's Title
*
Manager's Work Number or Extension
*
Date of incident
*
MM
DD
YYYY
Approximate time of incident
*
Location of incident
*
Injury or illness occurred as a result of incident
*
Specific task being performed at time of incident
*
Step-by-step events leading up to the incident
*
Equipment and/or tools involved
*
Materials being handled
*
Unusual condition(s)
*
Other relevant details
*
Witness name(s) and phone number(s)
*
When listing an employee, a phone number not required.
Conducted By
*
Date of evaluation
MM
DD
YYYY
Is this a “sharps injury” (i.e. needlestick, cut, or abrasion) with an object that may have been contaminated with blood or other potentially infectious material
*
Has the incident resulted in, or expected to result in, hospitalization for more than 24 hours
*
Has the incident resulted in, or expected to result in the person's death
*
Process and/or environment-related
*
Check all that apply.
If other selected, explain...
Personnel-related
Check all that apply.
If other selected, explain...
Posible root cause(s)
*
Factors contributing to the workplace condition(s) and/or act(s) identified above. Check all that apply.
If other selected, explain...
Additional details on possible cause(s)
*
Mark field as Not Applicable or N/A as appropriate.
Follow-up(s)
*
If other selected, explain...
Manager Comments
Additional Comments
Name of person completing report
*
First Name
Last Name
