First Report of Incident
PART 1: Description of Incident
Facility
Select a facility
Buffalo Grove - A
Buffalo Grove - N
Buffalo Grove - R
Buffalo Grove - W
Franklin - DVAF
Franklin - Technology Center
Lawrence
Oak Creek
Plain City
San Francisco
Santa Clara
Waukegan
Other
Incident Date
Incident Time
Incident Type
Select an incident type
Injury
Illness
Near Miss
Property Damage
Specific Location of Incident
Involved Person
First Name
Last Name
Title
Address
City
State
Employment Status
Select Employment Status
Yaskawa Full Time Associate
Yaskawa Part Time Associate
Temporary Contract Worker
Contractor
Visitor
Other
Affected Party Supervisor Name
Supervisor Email
Report Date
Name of Person Completing Form
If the report date is more than 24 hours after the incident, explain the reason for the delay:
Witness 1 Name
Witness 2 Name
Describe the incident in as much detail as currently known. Attach images or diagrams to improve understanding of what happened in this incident:
Were Emergency Services Called
Emergency Services Type
Select Emergency Services Type
Police
Fire
Ambulance
Incident Number
Treatment Account (Check as Appropriate)
None (Report Only)
Emergency Room
First Aid
Nurse Hotline
Clinic
Hospital
Refused Treatment
Injury Type
Bruising
Chemical Reaction
Concussion Headache
Dislocation Ligament
Electric Shock
Foreign Body
Fracture
Illness
Internal Organ
Laceration/Cut
Puncture
Scratch/Abrasion
Strain/Sprain
Syncope/Fainting
Other Injury
Injury Map
Click on the affected body parts
Upload Images
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