Incident Report | Tree-Ripe Fruit Co.

1

What are you reporting

Incident

An event that caused injury to a person, or damage to equipment, a building, or materials.

Near Miss

An event that could have caused injury or damage, but did not this time.

2

Who is involved

Form completed by

Date completed

Employee involved

Job title or role

Witnesses if any

3

When and where

Date of incident

Time of incident

Department and location

Shift started

Shift ended

4

Injury

Did an injury occur?

Yes No

Nature of the injury

Body part affected

Medical treatment received

Facility, hospital, or physician if seen

Hospitalized overnight?

Yes No

Left work early?

Yes No

What time did they leave?

Returned to regular duty date

Returned with light duty date

5

What happened

Describe the incident fully

Equipment, materials, or chemicals involved

What contributed to or caused it

6

Prevention

Were proper procedures being followed?

Yes No

Please explain

Was proper protective equipment being worn?

Yes No N/A

Please explain

Are equipment changes needed to prevent this happening again?

Yes No

Please explain

7

Sign and date

Employee signature

Your typed name counts as your signature.

Date

Supervisor signature

Your typed name counts as your signature.

Date