Close Out (Must be completed for all Injuries / Incidents)

Completion of this section, including necessary signatures, denotes closure of this incident report.

Final Incident Classification

Plant

Property

Other Details:

Complete for LTI or RWI (Lost Time Injury / Restricted Work Injury)

LTI

RWI

Is rehabilitation likely?

Yes

N/A

Return to Full duties on Date

Date of RTW

No. of Lost Days

Has the Workers Comp body been notified?

Yes

Not Required

By Whom?

Date

Time

Other Details:

Sign Off for All Incidents

Foreman

Name

Date

Time

Site Safety Officer

Name

Date

Time

Safety Manager

Name

Date

Time

Director

Name

Date

Time