Incident / Accident Report

Name : Date of Report :

Address: Incident No. :
£ Employee £ Customer £ Visitor £ Vendor
Incident Information / Description :

Type of Incident : Date of Incident :

Location of Incident :
Why -why Analysis :

Corrective Action :

Was there any witness to the incident ? £ Yes £ No If Yes,

Name :
Address :.
Phone No. :
Police Report Filed : Precinct:
Reporting Officer : Phone No. :
Follow Up Action :

Preventive Action :
Supervisor Name & Sign Date