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Injury and Lost Time Incident Report Sample Type of incident (injury, near miss, property damage, or theft) Location (Address) Date/time of incident. Name. Name of supervisor. Description of the incident, including specific job site location, the sequence of events, and the results of the event.
Accident report forms should include fields for names and contact information of the individuals and witnesses involved, the type of accident, the date and time the accident occurred, the location of the accident, a detailed description of the accident, and room for any additional comments.
Identifying the ?how?, ?when?, ?where? and ?whom? of the incident are important elements of a good report ? and all companies are most likely to emphasize these marks during the document development.
The report must contain the following sections: Incident Summary: The incident summary is a brief description of the accident or near-miss. ... Description of the Incident: This section should provide a detailed description of the incident. ... Cause of the Incident: This section should describe the cause of the incident.
Keep in mind that these three considerations are not to be confused with the three requirements for writing an incident report: The report must be factual and without assumption. An incident report must be accurate and without bias. The incident report must be complete.