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  • 5 Incident Report Form

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    Mitrabhanu Behera
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    This incident report form contains sections for documenting details of an incident involving employees or customers. It requests information such as the names and contact information of individuals involved, the date and location of the incident, a description of what happened and the nature of any resulting injuries or property damage. The final sections are for signatures and management contact information. The form is designed to collect essential facts about incidents in 3 sentences or less.

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    This incident report form contains sections for documenting details of an incident involving employees or customers. It requests information such as the names and contact information of individuals involved, the date and location of the incident, a description of what happened and the nature of any resulting injuries or property damage. The final sections are for signatures and management contact information. The form is designed to collect essential facts about incidents in 3 sentences or less.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
    10 views1 page

    5 Incident Report Form

    Uploaded by

    Mitrabhanu Behera
    This incident report form contains sections for documenting details of an incident involving employees or customers. It requests information such as the names and contact information of individuals involved, the date and location of the incident, a description of what happened and the nature of any resulting injuries or property damage. The final sections are for signatures and management contact information. The form is designed to collect essential facts about incidents in 3 sentences or less.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
    of 1

    Consort Digital Private Limited

    Level 3, Charmwood Plaza, Eros Garden,


    Surajkund, Faridabad – 121009, Haryana, India
    Tel: +91 129 4891255, Email: info@consortdigital.com

    Incident Report Form

    Employee Involved (Complete both boxes) Customer/Visitor/Employee Involved


    Name: Name:
    Job title: Address:
    Date of Birth: City, ST Zip:
    Phone: ( ) Phone: ( )

    The following sections should be completed for all incidents:


    Date of incident: Approximate time of incident: AM / PM
    Location of incident (be specific as to where, in what room or part of the property, etc):

    What happened, what was the cause of injury:

    What is the nature of the injury/ property damage:

    If injuries were involved, Ambulance used, Will seek medical attention, or


    Medical attention not being sought at this time. (Checking this box does not prevent future medical
    attention should you change your mind or condition worsens.)
    Were their witnesses? Yes No List names & phone # if other than employee:

    Involved Party Signature: Date:

    Employer/Management Use only


    Received By (PRINT): Date:
    Signature: Manager Phone:
    Company Name & Address:

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