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INCIDENT/INJURY REPORT
INFORME DE INCUDENTE/LESION

Employee / Empleado

First name/Primero Nombre*

Last name/Apellido*

Position/Posicion*

Supervisor/Supervisor

Company name/Nombre de Empresa*

First name/Primero Nombre*

Last name/Apellido*

INCIDENTE/LESION

Date of incident/injury?-Fecha del incidente/lesión*

Month

Day

Year

Time

:HoursMinutes

Location/La Localizacion*

Does injury require Hospital/Physician/ER?-La lesión requiere hospital/médico/emergencias?*

Yes/Si

No

Description of Incident/Injury-Descripción del incidente/lesión*

Employee Explanation/ Explicación del empleado*

Witnesses/El Testimonio*

Action Taken/Accion tomada*

Upload Optional/Subir Opcional

Prepared By/Preparado por*

Signature/Firma*

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