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1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the Injured Person's Information. Fill in their Name, W#, and select their Status by checking the appropriate box for Employee, Student, or Visitor. If applicable, provide the Supervisor's name and Job Position/Title.
3. Next, complete the Incident Information section. Input the Date, Location, and Time of the incident. Describe the Task being performed at that time and select the Incident Results by checking one or more boxes for Injury, Fatality, Property Damage, or Near-Miss.
4. List any Witnesses along with their contact numbers if available. Indicate the Number of Workdays Lost and provide a detailed description of how the incident occurred.
5. Answer questions regarding safety equipment provided and its usage. Finally, describe preventive measures for future incidents.
6. For incidents resulting in injury, indicate Medical Treatment received and address any concerns about work-relatedness.
7. Conclude by signing as Supervisor and dating your report before submitting it back to HR.

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