Security Incident Report Form - Free Download
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INCIDENT REPORT FORM
This form to be completed for all job-related injuries or illnesses – regardless of
extent.
Must be completed by supervisor within 24 hours of incident
SAIF Coordinator must receive notification within 24 hours of all incidents.
IF EMPLOYEE RECEIVES MEDICAL TREATMENT OR MISSES TIME FROM WORK, A WORKERS’
COMPENSATION CLAIM - FORM 801 MUST BE COMPLETED AND SENT TO THE SAIF COORDINATOR
WITHIN 24 HOURS.
Name ________________________________________________________________ Job Tile _________________________________
First Middle Last
AM AM
Date of Injury: Hour: PM Time Left Work: PM Date of Birth:
Department Name Name of Supervisor Date Reported to Supervisor
Exact Location of Accident: Name of Witness:
Describe Accident (What was injured worker doing; what objects, machines o materials were involved):
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
Regular Days Off Working Shift AM AM
PM to PM
Employee Signature: ________________________________________________________ Date: ___________________________
ACTION BODY PART INJURED NATURE OF INJURY
FIRST AID CASE ONLY HEAD FACE EYE ABRASION LACERATION PUNCTURE
REQUIRED DOCTOR’S CARE NECK BACK CHEST BRUISE FRACTURE BURN
HOSPITALIZED ARM HAND FINGER SPRAIN/STRAIN FOREIGN BODY POISON OAK
OSHA NOTIFIED LEG KNEE ANKLE COLD INJURY HEAT NJURY DEMATITIS
TIME LOSS FOOT TOE LOSS OF OCCUPATIONAL
NO INJURY/NEAR MISS OTHER _____________________________________ CONCIOUSNESS ILLNESS
OTHER ________________________________________
ADDITIONAL NOTES
SUPERVISORS MUST COMPLETE OTHER SIDE
