GREENVILLE WOODWORKERS GUILD
IN-SHOP ACCIDENT / INCIDENT REPORT

Circle type of occurrence.

1.  MAJOR ACCIDENT - Defined as any injury requiring treatment by medical professional.  This 
will trigger an accident investigation as required by the by-laws.


2.  MINOR ACCIDENT - Defined as other injury that results in bleeding, bruising to degree that 
work is terminated and any eye injury.  Exclusions, would be simple splinter removal and minor 
superficial skin abrasions.


3.  INCIDENT REPORT - Generated when a safety violation occurs even if no injury results.  (i.e. 
improper use of a machine that could have potentially have caused personal injury to the worker 
or bystanders, or damage to the machine.)

REPORT
NAME OF WORKER INVOLVED 
______________________________________________________
( phone #__________________)
DATE AND TIME____________________________________________________________________
MACHINE(S) &/OR TOOL(S) INVOLVED_______________________________________
DATE WORKER CERTIFIED ON MACHINE_________________________
DATE LIABILITY FORM SIGNED_____________________
DESCRIPTION OF INJURY AND ACTION TAKEN FOR TREATMENT
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
________________________________
DESCRIPTION OF INCIDENT AND HOW IT OCCURRED 
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________
CAUSE OF ACCIDENT/INCIDENT IN JUDGEMENT OF SUPERVISOR 
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
________________________________
NAME OF OTHER PERSONS PRESENT (With phone number and comments) 
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________



______________________________________________________________________________
SIGNED AND DATED BY SUPERVISOR (Phone number)


SUPERVISOR WILL NOTIFYTHE SUPERINTENDENT AND THE ASSISTANT SUPERINTENDENT OF THE 
OCCURRENCE , BY E-MAIL. THE ORIGINAL WILL BE PLACED IN THE LOCKED DRAWER AT THE SHOP.