Burlington Report - Hickok & Boardman Insurance Group

Incident Location or Address

City Department

Employee Name

First Last

Employee Phone

Employee Job Title

Employee DOB

Hire Date

Email*

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Time Employee Began Work

:

Description of Incident

Incident Details

Date

Witness(es)

Date Reported

First Aid Given

Yes
No

Date Worker Left Work

On Employer Premise

Yes
No

Time Worker Left Work

:

Have you sought or will seek medical attention for this injury?

Yes
No

Date Worker Returned

Medical Facility

Doctor

Treatment Given

Body Parts Injured

If "Other" or Multiple Body Parts," please describe:

Incident Reviewer

Supervisor's Name

First Last

Supervisor's Phone

Cause of Injury

Please select one

If "Other," or additional Please describe:

Cause of Incident

Please select one

If "Other" or additional, please describe:

Analysis

Steps Taken to Prevent Similar Occurence

Reinstruction of Employee
Reminder Instruction to All Employees
Personal Protective Equipment Required
Formal Disciplinary Action
Installation of Guard Device
Counseling of Employee

Explain:

Email

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City of Burlington: Report Of Event

Incident Details

Incident Reviewer

Cause of Injury

Cause of Incident

Analysis

Solutions

Our Company

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