INCIDENT FIRST REPORT Ver el Informe de Incidente Primario en español aquí. Incident First ReportINSTRUCTIONS Using this form, Team Members MUST report all work related accidents, injuries, illnesses. Or any unplanned events (incidents) which have resulted in issues or could have resulted in injuries. For example arguments with other staff or managers. For additional information and definitions please refer to the EDH Group Handbook located in the online library. I am reporting a work related: Injury Illness Near Miss Other / IncidentOther: (Please Describe) EMPLOYEE DETAILSFirst Name:Last Name:EDH ID:Contact Phone Number: LOCATION & SHIFT INFORMATIONPosition Assigned: Bartender Server Male Server Cook OtherOther Position: (Describe)Date of Shift:Scheduled Shift Start Time:Site Name: Crosswinds Valley Mansion OtherOther (Type in Event Name)Street Address:City / Town:Zip Code:State:- Select -AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming INCIDENT DETAILSLocation of Incident: (Describe what part of the building you were in when the incident occurred)Date of Incident:Time of Incident:List All Witnesses to the Incident:Was this reported to a Manager?: Yes NoIf Yes, Name of Manager Incident was Reported to:If No, why not?:INCIDENT DESCRIPTIONDescribe the tasks being completed and sequence of events when the incident happened:What parts of your body were injured? If a near miss, how could you have been hurt?:Do you have images of your injury?: Yes NoIf yes, attach photos here:Choose Photo Did you require medical treatment from a: Physician Hospital Both NoneIf yes, provide the name of the:Attending Physician:Date of Physician Visit:Time of Physician VisitHospital:Date of Hospital Visit:Time of Hospital Visit:BACKGROUND INFORMATIONHas this part of your body been injured before? Yes NoIf yes, when?If yes, describe previous treatment and results:ACKNOWLEDGEMENT I, acknowledge that by submitting this form, all statements made herein are true and correct to the best of my knowledge. I understand that EDH Group Inc. will contact me and any parties mentioned above to gain further information to assess the incident.Submit Form
