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create a form
Generated on: December 11, 2025
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This response was generated using your private uploaded documents and publicly available safety documents and regulations.
To create a safety incident report form, include sections for:
- Injured employee information (Name, Job Title, Incident Date)
- Time and date of the incident
- Location of the incident (be specific)
- Description of the incident (be specific)
- Part of body affected
- Type of incident
- Action taken by the company (First Aid, Medical Treatment, Lost Work Day)
- Personal Protective Equipment (PPE) in use at the time of the incident
- Witnesses
- What could have been done to prevent this accident/incident?
- Corrective actions to be taken
- Additional comments/notes
- Employee and Supervisor Signatures and Dates
[2] [3] [2] [2] [2] [2] [2] [1] [3] [3] [4] [3] The form should also include a section for the employee to report specific injuries and a space to illustrate the incident. [1] [1]
It is important to note that this form is for internal use and not intended to replace official reports like DCBS Form 801. [3]
Important Safety Note:
Always verify safety information with your organization's specific guidelines and local regulations.