Incident Report

Incident Report Form

This form is to be used by Clear Water staff is to to report all work-related illness, injury, and near-miss incidents, regardless of severity, on same day as incident. If you are not able to do so, you are required to call Angela immediately.

Prior Injury *

Employee Name *

Incident Description *

Does Current Incident Necessitate Medical Care? *

Yes

Incident Location *

Date and Time of Incident *

Part of Body Affected *

Witness *

Clear Water Technologies2220 Otay Lakes RoadSuite 502-107San Diego, CA 91915info@clearwatertech.com

Clear Water Technologies
2220 Otay Lakes Road
Suite 502-107
San Diego, CA 91915
info@clearwatertech.com