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HBI – Employee Incident Report (Direct Link)

HBI – Employee Incident Report (Copy)

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

Employee Name

Job Name

Supervisor's Name

Location of Incident

Date of Incident

MM slash DD slash YYYY

Time of Incident

Hours

:

Minutes

AM/PM

Type of Incident(Required)

Near Miss

Injury

Illness

Exposure to Infectious Materials

Damage – Property Material Equip.

Other (Please explain)

Type of Incident (Other)

Incident Description

Describe the work activities leading up to the incident and any tools, equipment, or material you were using. Be specific and detailed.”(Required)

List all witnesses:

Photo Upload (At least 1 photo required. No more than 10) (Required)

Drop files here or

Max. file size: 120 MB, Max. files: 10.

Employee Injury Description (Check all that apply)

Employee Injury Description

Strain

Fracture

Bruising

Internal

Laceration/Cut

Scratch/Abrasion

Puncture

Amputation

Burn/Scald

Impalement

Chemical Reaction

Foreign Body

If other, explain:

Part of Body Injured

Head

Face

Eye(s)

Nose

Mouth

Teeth

Ear(s)

Chest

Abdomen

Groin

Back

Shoulder

Arm

Elbow

Wrist

Hand

Finger

Leg

Knee

Ankle

Foot

Toe(s)

Other

Side of body

Right

Left

Bilateral (both sides)

Not Applicable

Other

Body Position

Sitting

Standing

Kneeling

Crawling

Walking

Other

Work Position

Working overhead

Working at same level

Working at ground level

Work activity

Reaching

Bending

Twisting

Pulling

Pushing

Climbing

Carrying

Lifting

Other

Medical Treatment

Medical Treatment

No Treatment

First Aid

Urgent Care Clinic

ER/Hospital

Other

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

Yes

No

If yes, please explain:

Recommendation on how to prevent this incident and/or prevent the hazard from recurring?(Required)

Incident Review – To be Completed By SUPERVISOR

Date Incident Reported

MM slash DD slash YYYY

Time Incident Reported

Hours

:

Minutes

AM/PM

Describe the task/activity the employee was engaged in at the time of the incident?

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

Direct / Immediate Causes(Required)

Defective Tools/Equipment

Unsafe work procedures

Insufficient procedures

Not following procedures

Improvising/Shortcuts

Unaware of potential hazards

Lack of safety devices

Not employee(s) normal job

Improper use of tools

Proper tools not available

Unauthorized equipment use

Guard removed/guard needed

Poor housekeeping

Violated safety rule(s)

Not wearing appropriate PPE

Other (Please explain)

Root Causes(Required)

Employee unaware of hazard

Complex procedures

Unclear instruction

Inadequate training

Inadequate comprehension

Lack of skill/knowledge

Failure to recognize unsafe act

Poor Attitude

Personality Conflict

Lack of training

Job design/workstation layout

Lighting

Weather conditions

Excessive production pressure

Communication error

Other (Please explain)

Please explain direct/immediate causes

Please explain root causes

Was the task and associated hazards discussed in pre-task planning?(Required)

If no, please explain.(Required)

Was PPE Required?

Yes

No (Please explain)

Was the correct PPE in use?

Yes

No

If Yes: List the PPE – If No: Explain

Please explain "Was PPE Required; other"

Was the appropriate level of PPE available and in use?

Yes

No (Please explain)

If No: Explain

Was the employee following HBI safe work practices when the incident occurred?

Yes

No

If No: Explain

What steps will be taken to prevent the recurrance of this type of incident?(Required)

Employee

Signature

Date

MM slash DD slash YYYY

Supervisor

Signature

Date

MM slash DD slash YYYY

Additional Email 1

Send a notification to an additional email

Additional Email 2

Send a notification to an additional email

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