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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
*
INCEIDENTE/LESION
Date of incident/injury?-Fecha del incidente/lesión
*
Month
Day
Year
Time
:
Hours
Minutes
AM
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
Upload File
Prepared By/Preparado por
*
Signature/Firma
*
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