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INCIDENT REPORT
PERSON INVOLVED IN INCIDENT
AM
PM
AM
PM
*Type of Incident (select all that apply)
Close Call (something happened but there is no injury or property damage)
Injury or Illness (include pulled muscle, cuts, burns, exposure to asbestos etc)
Equipment Failure (equipment was damaged, stopped working etc)
Environmental (spills, release of gas etc)
Property Damage (machinery, tools, etc was damaged)
Vehicle (collision, damage, vandalism etc.)
Other
*Was there witnesses to the incident?
Yes
No
*Was the invidiual injured?
Yes
No
*Was medical treatment provided?
Yes
No
*Where was the treatment provided?
On site
Emergency
Other
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