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Thursday, July 7, 2022
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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
Email address of your manager/supervisor
(Required)
Section 1 - Incident Type
Select the primary incident type
(Required)
Alarm Activation
Call to Law Enforcement
Facility Damage
Injury or Illness
Near Miss
Power Outage
Vehicle Accident
Why was law enforcement called?
(Required)
Theft or robbery (includes shoplifting)
Disturbance
Donated weapon
Threat of violence
Other
Incident Location
(Required)
Athens ATC
Athens store
Chillicothe ATC
Chillicothe (Western) store
Chillicothe (Zane) store
Corporate Office
Circleville store
Circleville/Pickaway County ATC
Jackson store
Logan store
McArthur ATC
McArthur store
Waverly/Pike County ATC
Waverly store
WCH ATC
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
Social Security Number
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
AM/PM
Date of Report
(Required)
MM slash DD slash YYYY
Time of Report
(Required)
Hours
:
Minutes
AM
PM
AM/PM
Time Shift Began
(Required)
Hours
:
Minutes
AM
PM
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)
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