Flash Incident Form

Incident Report

Incident Flash Report

This report contains confidential information for internal use only. If it includes health-related details, it may be subject to HIPAA regulations. Unauthorized disclosure or sharing is strictly prohibited and may result in disciplinary or legal action. Please record as much as you can on this Flash Report. This report will immediately notify management of the incident.
Name of person if applicable or describe property damage
Please note the Date of the incident.
Enter the Time the incident occurred.
Incident Type
Immediate Response
Briefly explain what happened. Include what the injured was doing prior to the incident, and what tools or equipment were in use at the time of the incident.

“Tom was changing the tooling on his CNC without gloves when the tool slipped and cut his fingers.”

Describe the injury or property damage to the best of your knowledge.

“Tom had a deep cut on all 4 fingers along the inside of his hand and his palm.”

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Please note anything you feel important that hasn’t been covered above.
Investigation

Follow Up Investigation

Investigation Members

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Lost Time
Recordable Injury
Was a Medical Professional consulted regarding this incident?

Additional Witness Identified

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SafeStart Story

Using your SafeStart trainng, please complete the following questions as throughly as possible.
SafeStart State Observation
What is your observation of the cause of the injury at the time of the incident.
SafeStart Errors Observation
What is your observation of the errors that occurred resulting in the incident.

Action Plan

Please record the action plan tasks with a description of task, due date and who the task was assigned. You may add as many action items as necessary.
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What changes do you suggest to prevent this incident from recurring?
If this report is for property damage, please estimate the value of the damage.

Maximum file size: 8.39MB

Please upload any pictures or documents detailing the incident. Also include files that include witness statements, etc.

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