Workplace Health and Safety Report

Current Date*

First Name*

Last Name*

Are you completing this report for a health and safety incident that happened to you?*

Yes No

Date of incident*

Describe the incident

Was first aid required?*

Yes
No

Was 911 called?*

Yes
No

As a result of this incident, does the individual require time off work?*

Yes
No
Unsure
Waiting on medical opinion

Please provide any additional information about the circumstances around this incident.*

By signing and submitting this report, you agree that the information provided is accurate to the best of your knowledge. You also understand and agree that during the process of investigating this incident, you may be called upon to answer questions. We are committed to providing a safe workplace and your cooperation is appreciated.

Signature