Lifebanc OSHA Incident Form **Do not leave any line blank. If it does not apply, enter N/A**Employee InformationName*Gender*MFAddress* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Date of Birth* MM DD YYYY Date of Hire* MM DD YYYY TitleDate the Incident Occurred* MM DD YYYY Time the Incident Occurred*Facility where Incident Occurred*Treatment InformationFacility*Physician*Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Mandatory Alcohol/Drug Testing Completed?YesNoMedical Treatment Received?*YesNoDescribe*Date of Arrival* MM DD YYYY Time of Arrival*Was the Employee Admitted?*YesNoIncident InformationDescribe the events surrounding the incident, detailing what, where, when, and how the incident occurred, be specific, for example, the worker was climbing a ladder while carrying roofing materials when the ladder slipped on the wet floor, worker fell 20 feet onto the concrete floor and hurt lower back:*What PPE was being utilized at time of incident?*Did an injury occur?*YesNoDid a death occur as a result of this incident?*YesNoDescribe the injury, detailing location on body, type, size, and include as much detail as possible:*Was a sharp instrument involved?*YesNoType/brand name of device involved in the exposure*Was instrument being used in its intended manner?*YesNoIf yes, did the instrument have any engineered safety features?YesNoIf yes, were the safety features activated at time of injury?*YesNoIf yes, did the exposure occur before, during or after activation?*BeforeDuringAfterCompleted byName*Date* Date Format: MM slash DD slash YYYY Title*Phone*EmailThis field is for validation purposes and should be left unchanged.
