Safety Incident Report

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Safety is a core value that guides everything we do. Promptly reporting incidents helps us protect each other, improve our workplace, and uphold our commitment to a safe and supportive environment for all.

WHEN TO USE THIS FORM: Use this form to record any workplace incident (accident, injury, property damage, etc.), capturing all essential details for compliance and prevention. The affected employee and manager should complete this form together as soon as possible after the incident.

Instructions and Reminders:

1. Get Red Safety Binder and follow Communication Flow

2. Contact FSS and Market Manager before Calling Medcore

  • West – Dan Nelson 509-438-2164
  • TV – Dustin Souza 208-451-5329
  • Magic/East/Utah – Chris Aldrich 208-532-9727
3. Medcore MUST be called before sending to provider unless a 911 Emergency

 

Based on initial assessment.
List the name(s) and contact details of the witness(es).
Describe the sequence of events, what happened just before and during the incident, and the outcome in detail. Include relevant facts: equipment involved, task being performed, environmental conditions, etc.
Manager, please input any other information about the incident. Any conditions or factors that contributed to the incident? DO NOT REPEAT THE EMPLOYEE'S COMMENTS OR CHANGE THEM INTO YOUR OWN WORDS.
Maximum file sizes 1MB each. Allowed file types are .jpg, .png, .gif, .tiff, .mov, .mp4, and .avi.
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