DISCIPLINARY REPORT

EMPLOYEE INFORMATION ACCIDENT INFORMATION

NAME DATE
AGE TIME
CONACT # LOCATION
POSITION WITNESS

DESCRIBE WHAT HAPPENED IN DETAIL INCLUDING TIMES AND LOCATIONS

DESCRIBE ALL DAMAGE IN DETAIL INCLUDING ANY PART OF THE BODY/PROPERTY AFFECTED IF
APPLICABLE

DID YOU SEEK MEDICAL PROFESSIONAL? IF YES, PROVIDE NAME, ADDRESS AND CONTACT NO.

WHAT ARE THE CONTRIBUTING FACTORS FOR THE

REMARKS FROM WITNESSES
INCIDENT?

CORRECTIVE MEASURES: ACTIONS NEED TO BE DONE TO PREVENT REOCCURENCE (COMPLETED BY

SUPERVISOR)

EMPLOYEE REPORTING INCIDENT:

SIGNATURE DATE

SUPERVISOR
SIGNATURE DATE