Support & Safety Reporting
Was this an Incident or an Accident?
Please Select
Incident
Accident
Date
-
Month
-
Day
Year
Date Picker Icon
Employee Name
First Name
Last Name
Investigated/Report completed by Name
First Name
Last Name
Date of incident/Accident
-
Month
-
Day
Year
Date Picker Icon
Time of incident/Accident
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Location
What (injury, nature and body part)
Please Select
N/A
Ankle
Arm
Foot
Hand
Head
Groin
Knee
Neck
Shoulder
Back
Chest
Knee
What (was the area conditions)
Please Select
Tidy, well lit, no obstructions.
Rubbish, debris, general untidiness.
Restricted space.
Ice, sleet, snow, Freezing
Where (actual location of incident/Accident)
Please Select
1st Fl - Cafeteria
1st Fl - Kitchen
1st Fl - Hallway
1st Fl - Daycare
1st Fl - Packing
1st Fl - Social Services
1st Fl - Front Office
1st Fl - Back Office
2nd Fl - Safe Exits
2nd Fl - Classroom
2nd Fl - Hallway
2nd Fl - FF4Fathers
2nd Fl - Studio
2nd Fl - Hub
2nd Fl - Clothing Rooms
2nd Fl - Difference makers
2nd Fl - Bike Room
2nd Fl - Large Classroom
Front Stairwell
Ashton Stairwell
Smallwood Stairwell
Front of Building
Side of Building
Back of Building
Dumpster Area
Van
Parking Lot
Street
Which (which task was being performed at the time of the incident/Accident?)
Please Select
Serving Client
Cleaning
Cooking
Delivery
Popup Market
Unloading
Loading
Picking
Packing
Put away
Driving
Administration
Computer work
Which (Which type Movement was being used at the time)
Please Select
Twisting
Turning
lifting
bending
walking
Stepping
repetitive movement
Description of Incident/Accident
Download Picture Here
Browse Files
Cancel
of
Employee Explanation/Notes
Witnesses (were there any and if so do you have statements?)
Please Select
Yes
No
Witness/Witnesses Names
What immediate containment measures have we put in place to prevent re occurrence?
Submit
Should be Empty: