Note: This report must be completed for any instance of injury or potential injury, observation of unsafe conditions or actions, or occurrence that involves emergency personnel (ambulance, fire department, police).
1. 2. 3. Date of Incident: Employee Completing Report:
INCIDENT / SAFETY HAZARD REPORT
Time of Incident: /
AM / PM
a) Person(s) involved (staff, residents, vendors, and/or others): b) Witnesses:
a) Specific incident location (name of building and location on property): b) Describe the incident/safety hazard thoroughly and in full detail (e.g., What task was being performed? What equipment was in use? What caused the incident? etc.) (attach additional sheets if necessary):
Did an injury occur? No (skip to question 6) Yes a) If yes, who was injured? b) Describe injury: c) Was first aid administered? Yes No Type of aid: d) Did/does injured/ill party intend to seek medical attention? Yes No e) Was person sent to hospital? Yes No If yes, which hospital? a) Emergency team(s) involved (police, fire department, paramedics): b) Police report filed? Yes No If yes, report number: Yes
Was any property damaged? No (skip to question 8) If yes, what was damaged? Describe the damage(s): How could this incident have been prevented? Actions taken to prevent recurrence: Is follow-up action needed? If so, what?
Additional Comments: Attach any supporting documentation, such as police report, photos, doctor’s report, witnesses’ statements. Signature of Employee Completing Report: Signature of Employee’s Supervisor: Signature of Department Director: Copies Sent to: ______________________________ Date: _______________ ______________________________ Date: _______________ ______________________________ Date: _______________ (HR Director), Insurance Company),