Incident Report Form

PERSON REPORTING (FULL NAME):

DATE AND TIME THE INCIDENT OCCURRED:

INCIDENT LOCATION (FULL ADDRESS):

PLEASE DETAIL THE INCIDENT IN YOUR OWN WORDS (INCLUDE AS MUCH DETAIL AS POSSIBLE):

ARE THERE ANY FACTORS YOU BELIEVE CONTRIBUTED TO THE INCIDENT?

WAS THERE ANY INJURIES TO EMPLOYEES?

WAS A VEHICLE DAMAGED?

WAS ANY FREIGHT DAMAGED?

WAS THERE ANY WITNESSES TO THE INCIDENT?

HAS THIS INCIDENT BEEN VERBALLY REPORT AS YET?

WHAT INITIAL ACTION HAS BEEN TAKEN (PLEASE INCLUDE AS MUCH DETAIL AS POSSIBLE):

I declare the information in this report is true and correct in every aspect.

* PLEASE INCLUDE ANY PICTURES WHERE POSSIBLE WITH THIS FORM *