Employee's Incident Report

Employee s Incident Report (to be completed by employee only) Today s Date: / / Time of this report: : am pm Employee Name: Date of Birth: / / (First) (Middle) (Last) Social Security Number: - - Home Telephone: ( ) Other Telephone: ( ) Home Address: City: State: Zip: Job Title: Date of Incident: / / Time Started Work: : am pm Time of Incident: : am pm Location of Incident: (Physical Address) (Area of worksite) In your words, describe fully how the incident happened, including what specific activity you were doing just before and when the incident took place, as well as the chain of events leading up to the incident: Include words such as pushing, pulling, climbing, etc..