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Goodwill of South Central Ohio

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Incident Report Form

Incident Report Form

IN CASE OF EMERGENCY

The HR/Safety coordinator and/or the appropriate senior administrator should be contacted immediately.

Incident report forms must be completed within 8 hours of the incident or by the end of shift.

Your name(Required)

First Last

Your email address

YOUR manager/supervisor email address(Required)

Section 1 - Incident Type

Select the primary incident type(Required)

Alarm Activation

Call to Law Enforcement

Facility Damage

Injury

Communicable Disease

Near Miss

Power Outage

Vehicle Accident

Use of Seclusion and Restraint (should not be used)

Aggression or Violence

Biohazardous Accident

Unauthorized Use and Possession of Legal or Illegal Substances

Overdose

Why was law enforcement called?(Required)

Theft or robbery (includes shoplifting)

Disturbance

Donated weapon

Threat of violence

Other

Incident Location(Required)

Athens GSC

Athens store

Chillicothe (Western) store

Chillicothe (Zane) store

Childcare Center

Circleville store

Corporate Office

Fayette GSC

Jackson store

Logan store

McArthur store

Pickaway GSC

Pike GSC

Ross GSC

Vinton GSC

Waverly store

WCH store

Warehouse

Other

Section 2 - Information for Primary Person Involved or injured in Incident

Select who was the primary person involved(Required)

Employee

Volunteer

Customer

Visitor

Other

Name of Primary Person Involved(Required)

First Last

Phone(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Employee Department(Required)

Employee Title(Required)

Date of Hire

MM slash DD slash YYYY

Gender

Female

Male

Nonbinary

Date of Birth

MM slash DD slash YYYY

Section 3 - Medical Treatment

Was the police/sheriff's department called?(Required)

YES

NO

Was the fire department called?(Required)

YES

NO

Was there an injury?(Required)

YES

NO

Was there a fatality?(Required)

YES

NO

Was anyone transported to the ER or Urgent Care for treatment?(Required)

YES

NO

Transported by:(Required)

Ambulance

Personal Vehicle

Agency Vehicle

Other

Medical Facility/Physician(Required)

Address of Medical Facility/Physician(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Medical Facility Phone Number(Required)

Section 4 - Occurrence Information

Type of injury or injuries(Required)

Strain/Sprain

Pain/Soreness

Laceration

Bruise

Pulled Muscle

Scratch/Abrasion

Burn

Swelling

Bite

Irritation

Fracture

Other

Where was the injury/injuries? (check all that apply)(Required)

Head

Right shoulder

Right elbow

Right wrist

Right hand and/or fingers

Left shoulder

Left elbow

Left wrist

Left hand and/or fingers

Waist

Back

Groin

Buttocks

Right thigh

Right knee

Right shin

Right calf

Right ankle

Right foot and/or toes

Left thigh

Left knee

Left shin

Left calf

Left ankle

Left foot and/or toes

If "other" please describe(Required)

Did the person ever injure these areas previously?(Required)

YES

NO

Was First Aid administered?(Required)

YES

NO

Was medical treatment offered?(Required)

YES

NO

Was additional medical treatment requested?(Required)

YES

NO

Date of Incident(Required)

MM slash DD slash YYYY

Time of Incident(Required)

Hours

:

Minutes

AM/PM

Date of Report(Required)

MM slash DD slash YYYY

Time of Report(Required)

Hours

:

Minutes

AM/PM

Time Shift Began(Required)

Hours

:

Minutes

AM/PM

If there is an injured employee or volunteer, put their shift start time. If it is another type of incident, the start time should be for the individual completing this report.

Describe the incident in detail(Required)

Was the person involved performing a regular job task when the incident occurred?(Required)

YES

NO

Had the person involved been trained to perform the job?(Required)

YES

NO

What equipment was involved?(Required)

List all other individuals involved including first name, last name, phone number, and if the person is an Employee, Volunteer, Customer, Visitor, or other.(Required)

If no one else was involved, input "none."

Who witnessed the incident? List first name, last name, phone number, and if the person is an Employee, Volunteer, Customer, Visitor, or other.(Required)

If there were no witnesses, input "none."

How could this incident be prevented in the future?(Required)

CAPTCHA

Goodwill of South Central Ohio

PO Box 93
10 S. Paint St.
Chillicothe, Ohio 45601

Corporate Hours:
8 a.m. - 5 p.m. Monday-Thursday
8a.m. - 4 p.m. Friday

Corporate Office: (740) 702-4000 info@gwisco.org

Our region spans 8 counties:
Athens
Fayette
Hocking
Jackson
Pickaway
Pike
Ross
Vinton

Our community employment services have been CARF accredited since 1999

Recent News

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November 29, 2023

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Goodwill opens first childcare center in Chillicothe

September 29, 2023

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