Note: Fields with ( * ) are to be filled compulsory.

• 00:00:00
• Your Name *
• Email *
• Name of Employee involved in the incident *
• Date of incident *
• Branch of Employee *NashvilleChattanoogaNorth GeorgiaKnoxvillePiney FlatsCookevilleTullahomaClevelandLavergneLondonBranch of Employee *
• Type of Incident *Injury/IllnessVehicle AccidentForklift IncidentType of Incident *
• Type of Injury (if occurred) Abrasion or ScrapeAmputationBroken BoneBruiseBurn (heat)Burn (Chemical)ConcussionCrushing (body part)Cut, Laceration, PunctureHerniaIllnessSprain. StrainType of Injury (if occurred)
• Part of Body affected in injury HeadFaceEyesEarsNoseMouthNeckShoulderArmElbowHandFingerChestStomachUpper BackLower BackLegKneeAnkleFootToePart of Body affected in injury
• Anticipated result from injury

  First Aid only

  Job Restriction

  Days away from work
• Describe fully how the accident happened? *
• What was employee doing prior to the event and what Equpment and tools were being used? *
• Was there any tools or PPE that could have prevented it and do we provide them? *
• In your opinion what caused the event? *
• Were there any safety steps the employee ignored and have they been trained on it? *
• In your opinion what could have Bailey done to prevent this event *
• In your opinion what could have the Employee done to prevent this event *
• Upload any photos of damage or the scene
• Submit