EK Flooring Incident and Injury Report

Incident and Injury Report

This form is to be filled out as soon as reasonably practicable after an incident or injury occurs
YesNo
Details of Incident

Property, Plant or Environmental Damage
Date of Incident*

DayMonthYear
Time of incident*

:HourMinutesAM/PM Option
Nature of Incident*
Location of Incident
Description of Incident*
Property DamageInjuries to PeopleBoth
Details of Property Damage
Details of Damage to Property*
Take photograph of Damage*
Details of Injury

injury and treatment details for any Workers, Visitors, Volunteers, etc. involved
Name of Injured Person*

First NameLast Name
Date of Birth*

MonthDayYear
Place of residence*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Telephone*
Occupation*
Activity in which the person was egnaged at the time of the injury*
Take photograph of exact Incident location*
FootAnkleCalfKneeThighWaistAbdominChestShoulderBack lowerBack UpperUpper ArmElbowForearmWristHandNeckHead
Treatment given on site*
Name of Person Treating*

First NameLast Name
YesNo
Name of Doctor or Hospital*
YesNo
Upload Med Cert*

Upload a File

Cancelof
YesNo
Report to Authorities
YesNo
Notify Rehabilitation and Return to Work Coordinator (RRTWC)
Name of RRTWC*

First NameLast Name
YesNo
Investigation

Fill this out for Incidents, Injuries & Near Misses
Cause of Incident, Injury or Near Miss*
Preventative Actions*
Completed by
Name*

First NameLast Name
Position*
Date Completed*

DayMonthYear
Should be Empty:

Incident and Injury Report