Error file size too large The uploaded file extension not valid DashboardSubmit TicketMy TicketsLogin Email Address * Full Name * Department * Select DepartmentMaintenanceSafetyAccident Investigation Phone Priority * Select PriorityLowNormalHigh Store # Date/Time: Activity: Value: Location Subject * This is an: Date Reported Company Department Supervisor 1. Name of Person Involved 2. Sex 3. Social Security Number 4. DOB 5. Date of Incident 6. Home Address and Phone 7. Time and Day of Incident 8. Specific Location of Incident 9. Employees Occupation 10. Job Task at Time of Incident 11. Date of Hire 12. Employee was Working: 13. Name, Address and Phone of Treating Physician 14. Employment Category 15. Experience in Occupation at Time of Incident 16. Name and Address of Hospital 17. Phase of Employees Workday at Time of Injury 19. Employees Wage (pay per Hour) 18. Name of employees immediate Supervisor 20. Other Witnesses 21. Voluntary benefits paid by the employer if any 22. PART of BODY INJURIED or AFFECTED 23. NATURE of INJURY or ILLINESS 24. DISPOSITION 25. DIAGNOSIS 26. SEVERITY 27. WHAT CONDITION CONTRIBUTED TO INCIDENT? 28. WHAT CAUSED THIS CONDITION? 29. WHAT ACTION CONTRIBUTED to the INCIDENT? 30. PROBABLE RECURRENCE 31. LOSS SEVERITY POTENTIAL 32. PREVENTINVE MEASURES: 33. EMPLOYEE’S DESCRIPTION of INCIDENT 34. SUPERVISOR’S DESCRIPTION of INCIDENT 35. SPECIFIC CORRECTIVE ACTIONS Issue Summary * Employee Name Todays Date Attachments Maximum File Size (3072KB)File Extension Type (doc,docx,odt,pdf,txt,png,jpeg,jpg) Add more Latitude Longitude Captcha Cancel Menu Other OptionsServices Donate Store Locations Careers About Us Mission-Vision & Values Leadership Ethics Board of Directors Contact Us 9611 Acer Ave. El Paso, TX 79925 (915) 778-1858 info@goodwillep.org
