"*" indicates required fields Store Location*- Select Location -Smyrna, GAAtlanta, GAJonesboro, GACollege Park, GAFairburn, GARiverdale, GAPonce de Leon, GANorman West, OKMoore, OKWarr Acres, OKReno, OKStillwater, OKRockwell, OKYukon, OKMidwest City, OKMustang, OKManager's Email* Employee Name* First Name Last Name Date of Incident:* MM slash DD slash YYYY Time of Incident:* Hours : Minutes AM PM AM/PM Date of Report:* MM slash DD slash YYYY Time of Report:* Hours : Minutes AM PM AM/PM Location of Incident:*Brief Description of Incident:*Did The Employee Report the Incident Immediately? Yes No Did you or someone else witness the incident? Yes No If someone else did, who? First Name Last Name Do you have any reason to question the legitimacy of the incident? Yes No If yes, please explain:Indicate the conditions that led to the incident: Unused/Unavailable lifting Equipment Unused/unavailable PPE (gloves) Unused/Unavailable sharps Container Unguarded Tools and Equipment Defective Tools or Equipment Electrical Obstructed View Lack of Training Wet /Slippery Floor Poor Housekeeping Interaction with co-worker Interaction with Resident Chemical Exposure Airborne Contaminants/Smoke Other If Other, please explainWhat changes could be made to eliminate or reduce the hazard(s) identified above?*Prepared by* First Name Last Name Signature*Title*Date* MM slash DD slash YYYY
