BCB Intranet - BCB Incident Report

BCB Incident Report - Injury or Illness

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Section 1 - Employee Information
1.1 - Name:
1.2 - Street Address:
1.3 - City:	, SC
1.4 - ZIP:
1.5 - Phone Numbers:	Home Cell
1.6 - Social Security #:
1.7 - Date of Birth:
1.8 - Gender:
1.9- Type of Employee:
1.10 - Date of Employment:
1.11 - Organization:
1.12 - Employee's Supervisor:
1.13 - Supervisor's Phone:
1.14 - Job Position:
Section 2 - Incident
2.1 - Date:
2.2 - Time:
2.3 - Location:
2.4 - Reported to:
2.5 - Date Reported:
2.6 - Employee's Description:
2.7 - Witnesses (optional):
Section 3 - Incident Details
3.1 - Type of Injury or Exposure:
If "Other", description:
3.2 - Activity Involved:
If "Other", description:
3.3 - Part of Body:
Further Details (if needed):
3.4 - Side of Body:
Section 4 - Reported By
4.1 - Person Completing Form:

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