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HBI - Employee Incident Report

HBI

EMPLOYEE INCIDENT REPORT

To be completed and signed by the injured worker, reviewed and signed by the supervisor,
and sent to the Safety Department. Use this form for near-miss incidents also.

Must be submitted within 24 hours

Incident Information

MM slash DD slash YYYY
Time of Incident
:
Type of Incident(Required)

Incident Description

Drop files here or
Max. file size: 120 MB, Max. files: 10.

    Employee Injury Description (Check all that apply)

    Employee Injury Description
    Part of Body Injured
    Side of body
    Body Position
    Work Position
    Work activity

    Medical Treatment

    Medical Treatment

    Was there any damage to property, material or equipment?(Required)

    Incident Review - To be Completed By SUPERVISOR

    MM slash DD slash YYYY
    Time Incident Reported
    :

    Please check all of the following which contributed to the incident?

    Direct / Immediate Causes(Required)
    Root Causes(Required)
    Was PPE Required?
    Was the correct PPE in use?
    Was the appropriate level of PPE available and in use?
    Was the employee following HBI safe work practices when the incident occurred?
    MM slash DD slash YYYY
    MM slash DD slash YYYY
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