Incident Report InstagramThis field is for validation purposes and should be left unchanged.Incident Type(Required)Select Incident TypeInjuryProperty DamageEnvironmentalOtherDepartment(Required)Select a Dept.Warehouse, Shipping, ReceivingWalther MfgFacilitiesServiceQualityOtherDate of the Incident(Required) MM slash DD slash YYYY Time Incident Occurred(Required) Hours : Minutes AM PM AM/PM Incident Reported Date(Required) MM slash DD slash YYYY Incident Reported Time(Required) Hours : Minutes AM PM AM/PM Manager / Supervisor(Required)Manager / Supervisor Email(Required) Specific Location of Incident(Required)Reported By(Required)Affected or Injured Persons Name(Required) First Last Was this part of the employees normal job duties? Yes Time on Job(Required)Length of time on the same job at the time of incident.Recent Performance & Attitude(Required) Good Acceptable Poor Specific Body Part's Injured(Required)What object or substance directly harmed the employee?(Required)Description of Incident / Injury / Damage Etc.(Required)Injury, Property Damage, Environmental, or OtherWere there any witnesses?(Required) Yes No Witness Name'sPlease list their names and phones numbersIncident Photos / Witness Statements / Other DocumentsMax. file size: 512 MB. Was First Aid or Emergency Response Provided?(Required) Yes No Describe First Aid or Emergency Response(Required)In Your Opinion What Caused Incident?(Required) Unsafe Procedure Unsafe Act Horseplay Unauthorized Use Housekeeping Defective Equipment Failure to observe Lack of Knowledge or Skill Reasonable Suspicion Alc / Drugs No Unsafe Factors Your recommendation to prevent this type of Incident from repeating.(Required)Corrective Action:(Required)
