Accident Incident and Witness Statement Accident Incident and Witness Statement Date of Incident:*Location of Incident:*Supervisor:*Was there an injury involved with this incident?:*-- Please Specify --InjuryNo InjuryHazardous SituationPlease specify if any of the following were administered:First AidMedical AidHold down the Control button and Click to select multiplesWho was hurt?: Employee Visitor Contractor Other What is your role in this incident?:*-- Please Select a Role --EmployeeSupervisorWitnessPlease upload any images or additional documentation you would like to include: Drop files here or Accepted file types: jpg, jpeg, png, pdf, docx, doc. Acceptable File Formats: .jpg, .jpeg, .png, .pdf, .docx, .docThis section to be completed by the employeeFirst Name:*Last Name:*Phone Number or Extension:*Job Title:*Department:*Time of Incident:* : HH MM AM PM Date Reported:*Employees Description of Alleged Accident / Incident:*Type of Incident:*Slip, trip or fallStruck by / against objectOver exertionRepetitive strainElectrical contactExposure to hazardous material / substancesCompany Property DamageContractors Property DamageOtherHold down the Control button and Click to select multiplesPlease Describe:*If this was a SLIP, describe footwear:*Witnesses To The Incident:*Name:Phone Number: What was the injury?*Please indicate what part of the body?:Did you seek or witness any medical treatment?*YesNoIf YES, please provide the following:*NameAddressPhone Number Treatment of Injury:*First AidWalk-in ClinicFamily DoctorEmergency RoomOtherPlease Describe:*Consent* By clicking this box I consent to enter this as an official company recordPlease Enter Your Full Name:*Date:* Date Format: MM slash DD slash YYYY This Section To Be Completed By The SupervisorContributing Factors:*Unsafe EquipmentInadequate illuminationNot or improperly guardedHazardous environmentInsufficient trainingImproper position/postureInsufficient careInfraction or unsafe practiceFailure to use PPEOperating without authorityFailure to lockoutOtherHold down the Control button and Click to select multiplesPlease Explain*Explanation of contributing factors:*Details of property damage:*Details of property damage:*To your knowledge, has the employee had a previous similar injury or has this similar hazard been reported before?* Yes No N/A Corrective Measures:*Request job safety analysisOn-the-job trainingPerform housekeepingReview PPEImprove work procedureCheck with manufacturerRe-training of person(s)Constructive DisciplineRepair or replace equipmentInstall safety guard / deviceReassignment of personOtherActions taken to prevent a reoccurrence (more than one item may apply). Hold down the Control button and Click to select multiplesExplanation of Corrective Measures:*Consent* By clicking this box I consent to enter this as an official company recordPlease Enter Your Full Name:*Date:* Date Format: MM slash DD slash YYYY Witness StatementWitness's Name:Date Date Format: MM slash DD slash YYYY (PLEASE PRINT STATEMENT OF ACCIDENT/INJURY BELOW)Injured Employee's Name:Witness Signature:(Typed Name as Signature Affirming Events)Date Date Format: MM slash DD slash YYYY EmailThis field is for validation purposes and should be left unchanged.