Incident Report

Name of Customer Injured or Property Damaged:

First NameLast Name

Phone # of Customer Injured or Property Damaged:

Format: (000) 000-0000.

Address Injury / Incident Took Place:

Street Address

Street Address Line 2

CityState

Zip Code

What person/substance/object caused the injury?

Safety Equipment that was required (if none, write "None"):

Safety Equipment that was used (if none, write "None"):

Was First Aid provided to Injured Person?

Injured Person was treated by:

Were the Police called (Property Damage)?

Estimated value of Damaged Property

Take photo of Injury / Damaged Property

Photo 2

Please call or text Jay Groth, HR Manager with Jay Consulting Group, with any questions or for status on Return to Work at (616) 541-5081, JGroth@jayinc-hr.com.

First Report of Injury / Incident

First Report of Injury / Incident