Incident/Accident Report – Kelly Express Mart

Date of Incident
Date Format: MM slash DD slash YYYY
Time of Incident

: HH

MM
Date Reported
Date Format: MM slash DD slash YYYY
Time Reported

: HH

MM
Location
Building/Site:
Specific Location:
Name of Injured/Accident:
Sex
Describe Incident/Accident:
Describe Loss/Injury:
Weather Conditions (if applicable):
Describe Medical Treatment/First Aid:
Witness(es):
Phone Number:
Witness Description of Incident/Accident:
Person/Entities Contacted:
Suggested Corrective Action:
Signature of Injured/Affected Person:
Date
Date Format: MM slash DD slash YYYY
Signature of Witness(es):
Date
Date Format: MM slash DD slash YYYY

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