Lifebanc OSHA Incident Form

**Do not leave any line blank. If it does not apply, enter N/A**

Employee Information

Name*

Gender*

M
F

Address*

Street Address Address Line 2 City State ZIP Code

Date of Birth*

MM

DD

YYYY

Date of Hire*

MM

DD

YYYY

Title

Date the Incident Occurred*

MM

DD

YYYY

Time the Incident Occurred*

Onsite Arrival Time for Shift*

Facility where Incident Occurred*

Treatment Information

Facility*

Physician*

Address*

Street Address Address Line 2 City State ZIP Code

Alcohol/Drug Testing Requested by Supervisor?

Yes
No

Alcohol/Drug Testing Completed?

Yes
No

Medical Treatment Received?*

Yes
No

Describe Test Completed, Treatment Details & Restrictions*

Date of Arrival*

MM

DD

YYYY

Time of Arrival*

Was the Employee Admitted?*

Yes
No

Incident Information

Describe the events surrounding the incident, detailing what, where, when, and how the incident occurred, be specific, for example, the TRS was recovering a hemipelvis with a scalpel in SRS3 & slipped and cut left thumb @ joint*

What PPE was being utilized at time of incident?*

Did an injury occur?*

Yes
No

Did a death occur as a result of this incident?*

Yes
No

Describe the injury, including which side on body, type, size, and include as much detail as possible:*

Was a sharp instrument involved?*

Yes
No

Describe in detail device involved in the exposure, including type & brand*

Was instrument being used in its intended manner?*

Yes
No

If yes, did the instrument have any engineered safety features?

Yes
No

If yes, were the safety features activated at time of injury?*

Yes
No

If yes, did the exposure occur before, during or after activation?*

Before
During
After

Completed by

Name*

Date*

Title*

Phone*

Name

This field is for validation purposes and should be left unchanged.