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Safety & Health - Employer Incident Report Form
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feedback
form.
Number of Affected Employees
Fatalities
Fatalities
(optional)
- None -
0
1
2
3
4
5
6
7
8
9
10
Other…
Enter other…
(optional)
In-Patient Hospitalization
In-Patient Hospitalization
(optional)
- None -
0
1
2
3
4
5
6
7
8
9
10
Other…
Enter other…
(optional)
Loss of an Eye
Loss of an Eye
(optional)
- None -
0
1
2
3
4
5
6
7
8
9
10
Other…
Enter other…
(optional)
Amputation
Amputation
(optional)
- None -
0
1
2
3
4
5
6
7
8
9
10
Other…
Enter other…
(optional)
Employer Information
Employer Name
Employer Contact Name
Title
Title
(optional)
- None -
Miss
Ms
Mr
Mrs
Dr
Other…
Enter other…
(optional)
First
Last
Business Activity
Employer Phone Number
Employer Fax Number
(optional)
Employer Email Address
Business Information
Federal ID#
(optional)
NAICS Code
(optional)
You can look up your NAICS code
here
.
Total Employees
(optional)
Address Information
Incident Address
Incident Address
Address
Address 2
(optional)
City/Town
State/Province
- Select -
Alabama
Alaska
American Samoa
Arizona
Arkansas
Armed Forces (Canada, Europe, Africa, or Middle East)
Armed Forces Americas
Armed Forces Pacific
California
Colorado
Connecticut
Delaware
District of Columbia
Federated States of Micronesia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Marshall Islands
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Palau
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Nova Scotia
Northwest Territories
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon
ZIP/Postal Code
Employer Mailing Address
Employer Mailing Address
Address
Address 2
(optional)
City/Town
State/Province
- Select -
Alabama
Alaska
American Samoa
Arizona
Arkansas
Armed Forces (Canada, Europe, Africa, or Middle East)
Armed Forces Americas
Armed Forces Pacific
California
Colorado
Connecticut
Delaware
District of Columbia
Federated States of Micronesia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Marshall Islands
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Palau
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Nova Scotia
Northwest Territories
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon
ZIP/Postal Code
Ownership
Ownership Type
Private
(optional)
Local Government
(optional)
State Government
(optional)
Federal Agency
(optional)
Other…
(optional)
Enter other…
(optional)
Union
Union
Yes
(optional)
No
(optional)
Accident Information
Accident Date and Approximate Time
Accident Date and Approximate Time: Date
Accident Date and Approximate Time: Time
Victim Information
Re-order
Victim Name
Victim Age
Occupation
Employment Type
Weight
Operations
Victim Name
(optional)
Victim Age
(optional)
Occupation
(optional)
Employment Type
Regular Employee
(optional)
Temporary Employee
(optional)
Contractor
(optional)
Item weight
(optional)
Add more items
(optional)
more items
Next of Kin Information
(optional)
Re-order
Name
Phone Number
Email
Weight
Operations
Name
(optional)
Phone Number
(optional)
Email
(optional)
Item weight
(optional)
Add more items
(optional)
more items
Accident Description
Accident Description
Preceding Circumstances
Description of Injury / Illness
Attached Files
(optional)
One file only.
50 MB limit.
Allowed types: gif, jpg, jpeg, png, bmp, eps, tif, pict, psd, txt, rtf, html, odf, pdf, doc, docx, ppt, pptx, xls, xlsx, xml, avi, mov, mp3, mp4, ogg, wav, bz2, dmg, gz, jar, rar, sit, svg, tar, zip.
50 MB limit per form.
Signature
Signature
I agree all information that I am submitting is true to the best of my knowledge.
Signed By
First
(optional)
Middle
(optional)
Last
(optional)
Signatory's title
Signatory's email address
Signed Date
Leave this field blank
(optional)