Incident Report Form

top of page

ECF ENGINEERING

CONSULTANTS

HOME
ABOUT
SERVICES
PROJECTS
CAREERS
CONTACT
INSIGHT
More

Use tab to navigate through the menu items.

INCIDENT REPORT FORM

1. GENERAL INFORMATION

Date of Incident

Time of Incident

Date Reported

Location of Incident

Reported By

Job Title

2. PERSON(S) INVOLVED

Name

Job Title

Department

Employee ID (if applicable)

Supervisor's Name

3. INCIDENT DETAILS

Type of Incident (Check all that apply)

Injury

Equipment Damage

Property Damage

Near Miss

Other

If Other, what type of incident:

Describe what happened (Include specific details of the incident, including actions leading up to the event)

Was there any equipment or machinery involved?

Yes

No

Were there any hazardous conditions (e.g., wet floors, faulty equipment)?

Yes

No

4. WITNESS INFORMATION

Were there any witnesses?

Yes

No

If yes, provide names and contact details:

5. INJURY DETAILS (If applicable)

Nature of Injury (e.g. cut, burn, sprain)

Body Part Affected

Did the employee seek medical attention?

Yes

No

If yes, where? (e.g. onsite first aid, hospital, urgent care)

Was medical leave required?

Yes

No

6. ACTION TAKEN

Immediate actions taken (e.g., first aid, equipment shutdown, area secured):

Was the incident reported to a supervisor or HR?

Yes

No

Was an investigation initiated?

Yes

No

Corrective actions recommended/implemented:

7. REPORTING AND SIGNATURES

Your Name and Signature:

Reported by

Date

Signature

Name and Signature of Supervisor/Manager:

Supervisor/Manager

Date

Signature

Name and Signature of HR/Safety Representative:

HR/Safety Representative

Date

Signature

Thank you for your report.

ECF Headquarters

4401 Beacon Circle

West Palm Beach, FL 33407

ECF Plantation Office

300 S Pine Island Rd, Suite 3033

Plantation, FL 33324

Social Media

Sitemap

ECF Atlanta Office

400 Perimeter Center Terrace NE, Suite 125, Atlanta, GA 30346

bottom of page