First Report of Incident
1. Description of Incident
Facility
Select a facility...
Buffalo Grove - A
Buffalo Grove - N
Buffalo Grove - R
Buffalo Grove - W
FR1
FR2
Lawrence
Plain City
San Francisco
Santa Clara
Waukegan
Other
Incident Date
Incident Time
Incident Type
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Injury
Illness
Near Miss
Property Damage
Specific Location inside Facility
Detailed Description of Event
2. Involved Person & Reporting Info
First Name
Last Name
Job Title
Employment Status
Select status...
Yaskawa Full Time Associate
Yaskawa Part Time Associate
Temporary Contract Worker
Contractor
Visitor
Other
Supervisor Name
Supervisor Email
Report Date
Person Completing Form
Reporting Delay Explanation (>24 hrs)
Witness 1 Name
Witness 2 Name
3. Emergency Services & Treatment
Were Emergency Services Called?
Emergency Services Type
Select type...
Police
Fire
Ambulance
Police/Emergency Incident #
Treatment Provided (Check all that apply)
None (Report Only)
First Aid
Nurse Hotline
Clinic
Emergency Room
Hospital
Refused Treatment
4. Injury Details & Affected Body Parts
Select Injury Type(s):
Bruising
Chemical Reaction
Concussion / Headache
Dislocation / Ligament
Electric Shock
Foreign Body
Fracture
Laceration / Cut
Puncture
Scratch / Abrasion
Strain / Sprain
Syncope / Fainting
Other
Interactive Injury Map
Click or tap on the affected body part(s) on the diagram below to select them.
FRONT
BACK
HEAD DETAILS
HANDS
5. Attachments & Submission
Upload Photos or Diagrams
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Submit Incident Report
