Injury/Incident Report

Inury/ Incident Report

Instructions: Contractor shall use this form to report any work related issues/incidents,no matter how minor, within 24 hours of it happening.
Today's date *

Month Day Year
Date
Name *

First Name Last Name
Phone Number *

Area Code Phone Number
Email *
example@example.com
Date of incident *

Month Day Year
Date
Time of incident *

: Hour Minutes AM/PM Option
Event & location the injury happened *
Describe clearly and in detail what happened/how you were injured *
What were you doing at the time of the incident/injury? *
Part(s) of the body that was injured (be specific - such as left hand or right thumb) *
Who did you report the incident/injury to? *
When did you report the incident/injury? (give date /time and explain any delay in reporting) *
What could have been done to prevent this incident? *
Name of all witnesses *
I confirm all of the information provided on this document to be mine and true. *

Clear
M.A.D. Models, LLC.

P.O. box 591401

San Antonio, TX 78259

(210) 444.2623

Admin@BookMadModels.com

www.BookMadModels.com

www.applytomadmodels.com
Client *
Should be Empty: