Managers Incident Report | Solid Learning Portal

MANAGER’S INCIDENT REPORT

Managers Incident REPORTING PROCEDURES

This report form should be completed at the earliest opportunity after a manager receives notification that one of their direct reports was in involved in a safety incident. If you are unable to complete the form within 12 hours of an incident you should inform your direct supervisor.

This form will automatically be sent to FLEET, HR and SAFETY. The purpose of early notification to these parties is to ensure that the injured party receives the appropriate treatment and investigations can be completed as soon as possible. Failure to complete this form in a timely manner will result in disciplinary action.

Additional Statement Forms

Please download the necessary statement forms using the links below.

Statement of Involved Party

Driver’s Accident Report

Witness Statement

Third–Party Statement

Refusal of Medical Attention Affidavit

Basic Information

Company Name:

Managers Name:

Managers Title:

Managers Email Address:

Managers Contact Number:

Injured Employees Name:

Injured Employees Title:

Injured Employees Address:

Injured Employees Number:

Gender:

Date of Incident Known?

Date of Incident:

Time of Incident (use 24 hour format)

Date Incident was Reported to Manager:

Time Incident was Reported to Manager:(use 24 hour format)

Location of Incident

Indoors or Outdoors?

Brief Description of Incident

Injury Specifics

What body part(s) were affected and how?

Were others involved? If so, list their names and injuries:

Were there any witnesses? If so, list their names:

Medical Treatment

Anyone taken from scene in ambulance? If yes, who:

List Physician / Clinic / Hospital:

Drug & Alcohol Post Incident / Accident Test Performed:

Drug & Alcohol Test Completed By:

Date of Test

Vehicle Incident Specifics (If Applicable)

Weather/Road Conditions:

Vehicle One

Vehicle 1:

Tag #

Was the Vehicle Towed:

If yes, where:

Driver’s Name:

Year

Make

Model

Color

Description of Damage:

Vehicle Two

Vehicle 2:

Tag #

Was the Vehicle Towed:

If yes, where:

Driver’s Name:

Year

Make

Model

Color

Description of Damage:

Additional Vehicle’s Insurance Company:

Policy #:

Police Report

Were police called to the scene?

Any citations issued?:

Police Report #:

Police Dept. Location:

Who responded?

Incident Photos or Forms

Submit any additional photos and forms you have available without delaying this report.

Please only click submit once and wait a few seconds, as additional clicks will send duplicate emails