INFORMATION ABOUT PERSON INVOLVED IN THE INCIDENT

Full Name

Phone

Birthdate (MM/DD/YY)

Position

Gender

Male

Female

Were you wearing socks?

Grip Socks

Regular Socks

Barefeet

INFORMATION ABOUT THE INCIDENT

Date of Incident (MM/DD/YY)

Time of Incident (example 13:00)

Location of Incident

Equipment involved in the incident

Cause of the Incident

Body part affected as a result of the Injury

Information about any administered treatment given

Full description of the Incident (What happened, how it happened, factors leading to the event, etc.) Please be as specific as possible {attach additional sheets if necessary}

Medical Attention

Yes

No

Police Notified

Yes

No

Were there any witnesses to the incident?

Yes

No

Please sign if the person involved with the incident is an adult: By signing this, I have told everything based on the facts and understand that giving false information can disadvantage and worsen the situation.

MANAGER / SUPERVISOR ON DUTY

Full Name

Position

Action to be taken:

Verbal Warning

Written Warning

Probation

Termination

Medical Leave

None

Other comment if any:

Witness Signature : By signing this, I have told everything based on the facts and understand that giving false information can disadvantage and worsen the situation.

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