Safety Notification Form
Tell us what happened, so we can help
Your Name
*
First Name
Last Name
Your Postion
Your Contact Number
Format: (000) 000-0000.
What are you reporting?
*
Injury
Incident (Including bullying & harassment)
Near Miss
Hazard
What happened?
Provide an overview of what happened
What was/is the hazard?
Provide an overview
What is the status of Hazard
Made safe
Further action required
Not Sure
When did it happen?
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
What time about?
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
What is the address?
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Location Information
Where For example section of the warehouse or the particular piece of equipment that the incident involved.
Injuredperson’s name (if any):
Further Treatment Required?
None
First Aid
Other
Current Status?
For example are they at, first aid room or is medical assistance needed.
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