Note: One of these reports should be filled out each time there is an incident that could result in personal

This report should be completed within 24 hours of the occurrence.

* 1. Employee Information

Employee's Description of Incident

* 2. Date of Incident

Please enter the date that the incident occurred

* 3. What Happened?
(What acts failures to act, and/or condition contributed most directly to this incident... Who?, What?, Where?, When?, Why?, and How?)

* 4. Why did the incident happen?

* 5. Which of the following may have contributed to the incident and may require additional attention.
(Select item or items)

* 6. What could have been done to prevent this incident?

* 7. What is your plan of action to prevent re-occurrence of this type of incident in the future?

* 8. Follow-up Required?

* 9. Who should follow-up?

NOTE: Attach extra sheets if needed along with drawings or sketches and send to: Todd Cook, Safety Specialist, 5070 N. 35th Street, Milwaukee, WI 53209 or