ConXtech Initial Incident Report

ConXtech Initial Incident Report

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ConXtech Initial Reporting Form
ConXtech Initial Reporting Form
Investigation Process
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    Select the Form you want to LOAD.
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    Injury or Illness

    Any work-related injury or illness that results in loss of consciousness, days away from work, restricted work, or transfer to another job needs to be recorded on the OSHA 300 Logs. Please use this form to provide the necessary information for tracking, trending, and prevention.

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    Be specific i.e. Left Thumb, Right Forearm
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    Please be specific and provide information of tools, equipment, materials, employee behavior that may have contributed to the incident.
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    To the best of your knowledge, select what contributed to the incident.
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    Detail out what failed
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    Select additional image (optional)
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    Near Miss Incident

    A near-miss is a potential hazard or incident that has not resulted in any personal injury. Some examples of near-misses are unsafe conditions, improper use of equipment, use of faulty equipment, not following proper procedures…. It is everyone’s responsibility to report and correct any of these potential hazards immediately. Please use this form to report near-misses and assist us in preventing future incidents.

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    What failed that caused the Near Miss
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    List all employees and departments involved in this incident
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    Opportunity for Improvement

    Continuous improvement is an organized approach to identifying opportunities for improvement that can help an organization meet its goals for increasing profits, reducing costs, and accelerating innovation. Opportunities also enhance the quality of a product or service, and improve safety.

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    Who is the Opportunity coming from?
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    Describe what happens now, what risks are involved.
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    Required Field
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    ConXtech Safety Team Notification List

    The following people will receive this notification:

    TJ Simmons, Khoi Nguyen, Joe Wilkins, Rogelio Garcia, Max Simmons, Miguel Rivera, Greg Gilliand, Chris Costa, Osvaldo Garcia, HR Dept.

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