Detailed Incident Report
PART 1: Description of Incident
Incident #:
Facility
Incident Date
Incident Time
Incident Type
Specific Location of Incident
Involved Person
First Name
Last Name
Job Title
Address
City
State
Employment Status
Affected Party Supervisor Name
Supervisor Email
Report Date
Reason for delay:
Name of Person Completing Form
Incident Details
OSHA
Workers Compensation
EHS
Witness 1 Name
Witness 1 Type
Incident Details
Emergency Services Called
Emergency Services Type
Incident Number
Treatment Account
Injury Type
Affected Body Parts
Uploaded Images
Recordable Y/N
Select
Yes
No
Recordable Reason
Select
Fatality
Days Away
Job Transfer or Restriction
Other Recordable
Away From Work Days
On Job Transfer or Restriction Days
Injury or Illness Type
Select
Injury
Skin Disorder
Respiratory Condition
Poisoning
Hearing Loss
All other illnesses
Enter a brief description of the injury or illness for the OSHA log
WC (Y/N)
Select
Yes
No
First Aid Provided
Updated Description
Type Of Incident
Select
Electrical
Powered Vehicle
Slip, Trip, or Fall
Tools & Machines
Crains & Hoists
Ergonomics/Over-exertion
Lifting
Struck-by/Struck-against
Cut by/Punctured by
Other
Icon Type
Select
Medical Attention
Report Only or First Aid
Near Miss
Property Damage
Corrective Actions
Identify the Problem
Expand
CA Completed By
Containment Action
Expand
Root Cause Analysis
Expand
Upload Root Cause Documents (PDF, Word, Excel, Image)
Assigned To
Status
Select
Open
In Process
In Verification
Closed
Corrective Action
Expand
Upload Corrective Action Evidence (PDF, Word, Excel, Image)
Completion Date
Update Corrective Action
Submit
