Wells & Associates, LLP

200 prospect street

East Stroudsburg, pa 18301
Wellsllp.com

Employee Incident Report

Date 2/25/19

Employee Manager
Name John Smith Name Jason Paliswiat
Title/position Forklift Driver Title/position Shipping Coordinator

Incident
Date 2/25/19
Time 3:40 pm
Location Wells & Associates Shipping Distribution Warehouse

Description of incident (if additional space is needed, use page 2)

Mr. Smith was moving stock through a tight area and the forklift hit a support beam holding up a
shelf damaging a large amount of the company’s stock.

Employee explanation (if additional space is needed, use page 2)

Mr. Smith said the throttle got stuck which caused him to lose control of the forklift.

Witnesses
The people at the scene were Mark Davis, Rachel Rodriguez, Justin Garcia, Paul George,
Samantha Ray, Amber May, and Walker Jones.

Action to be taken
 Verbal warning  Probation  Dismissal
 Written warning  Suspension  Other
Explain rationale The employee broke multiple rules during the incident. When
changing direction in the vehicle you need to come to a complete stop first. Secondly, in the lead-up
to turning the vehicle, he was going above regulated speed in that area. After an examination of
the forklift there is no reason to believe the throttle got stuck.
By signing this document, you acknowledge that you have read and understood the
information contained herein.

Employee Manager
2/25/19 2/25/19

Date Date
WELLS & ASSOCIATES, LLP INCIDENT REPORT P. 1
An idea that should be taken into consideration to help prevent this from happening
again is move the stock over. Doing so we can create a bigger aisle for the workers.
Also, on top of the OSHA requirement of being certified to drive a forklift every three
years Wells & Associates should require a training course every 6 months to a year
to make sure our employees are up to date on the latest rules and regulations.

WELLS & ASSOCIATES, LLP INCIDENT REPORT P. 2