JMA INCIDENT REPORT FOR PROPERTY DAMAGE
Name:
*
First Name
Last Name
Date of Incident:
*
-
Month
-
Day
Year
Date
Location of Incident:
*
Time of Incident:
*
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
NAME OF ALL PARTIES INVOLVED INCLUDING WITNESSES:
*
DESCRIPTION OF INCIDENT:
*
ACTION TAKEN:
*
Employee Signature:
Name: Print
First Name
Last Name
Title:
Date:
-
Month
-
Day
Year
Date
Individual Completing This Form: Print
*
First Name
Last Name
Individual Completing This Form: Signature
*
Email
example@example.com
Title:
*
Date
*
-
Month
-
Day
Year
Date
THIS NEXT SECTION IS FOR SUPERVISOR'S ONLY! IF YOU ARE NOT A SUPERVISOR PLEASE SCROLL DOWN PRESS THE SUBMIT BUTTON.
SUPERVISOR'S NOTES/ OTHER COMMENTS: **(IF YOU ARE NOT A SUPERVISOR PLEASE SKIP THIS SECTION!)
Supervisor: Signature
Supervisor: Print
First Name
Last Name
Supervisor: Title
Date
-
Month
-
Day
Year
Date
Was drug/alcohol test given?
YES
NO (If you select this option, please answer the following question and explain why.)
If no, explain reason for no testing:
Received By: HR/ Safety Manager Signature
Date Received:
-
Month
-
Day
Year
Date
**NOTE: IF ANYONE WAS INJURED DURING THIS INCIDENT, AN INCIDENT REPORT OF INJURY MUST BE COMPLETED!**
Submit
Should be Empty: