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Honolulu
Employee Incident Report
INFORMATION ABOUT PERSON INVOLVED IN THE INCIDENT
Full Name
Phone
Birthdate (MM/DD/YY)
Position
Gender
Male
Female
Were you wearing socks?
Grip Socks
Regular Socks
Barefeet
INFORMATION ABOUT THE INCIDENT
Date of Incident (MM/DD/YY)
Time of Incident (example 13:00)
Location of Incident
Equipment involved in the incident
Cause of the Incident
Body part affected as a result of the Injury
Information about any administered treatment given
Full description of the Incident (What happened, how it happened, factors leading to the event, etc.) Please be as specific as possible {attach additional sheets if necessary}
Medical Attention
Yes
No
Police Notified
Yes
No
Were there any witnesses to the incident?
Yes
No
Please sign if the person involved with the incident is an adult: By signing this, I have told everything based on the facts and understand that giving false information can disadvantage and worsen the situation.
Clear
MANAGER / SUPERVISOR ON DUTY
Full Name
Position
Action to be taken:
Verbal Warning
Written Warning
Probation
Termination
Medical Leave
None
Other comment if any:
Witness Signature : By signing this, I have told everything based on the facts and understand that giving false information can disadvantage and worsen the situation.
Clear
Submit Report
Thanks for submitting!
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