"*" indicates required fields This report is for potential hazards or incidents in which no workplace injury/illness was sustained. To ensure a safe work environment, the company requests that all employees report and correct any of these potential hazards immediately. In the event of serious injuries or death contact Emergency Services, then First Response immediately. Accidents and workplace injuries/illnesses are to be called into First Response and are reported on their own forms, do not use this form. Contact First Response at: 800-854-3632 ext 2244 Incident Report Company Selection*UACLUACL SpecializedUACL CanadaFirst Name (Person Reporting Incident)* Last Name (Person Reporting Incident)* Time of Incident* Hours : Minutes AM PM AM/PM Date of Incident*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Location of Incident* Type of Incident*Near-MissProperty DamageEquipment DamageHealth & Safety HazardSecurity BreachWorkplace MisconductGovernment InspectionOtherPlease Specify* Government Inspection Type*OSHAEPAFire MarshallOtherPlease Specify* Supervisor's Full Name* Supervisor's Contact Number* Contact Number Extention Incident Details / Description*Reporting Emergency Services Information, Including Report Number (If Applicable)Witness (First Name, Last Name, and Contact Number)Additional InformationCAPTCHANameThis field is for validation purposes and should be left unchanged.
