Serious Event Reporting Form EMERGENCY NOTICE Do Not Report an Emergency Using this Form or Email To report an emergency, please use our VOSH Complaint form Step 1 of 2 50% Information about the location where the incident occurred Name of Location (or Description)* Address* Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Information about the incident Date incident occurred* MM slash DD slash YYYY Time incident occurred* : Hours Minutes AMPM AM/PM What Happened?* Number of Fatalities Number of Hospitalizations Employer Information Legal Business Name* Other Name (DBA) Business Address* Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Information for persons who VOSH can contact Contact #1 Name* First Last Title* Work Phone* Cell Phone Email Address* Contact #2 Name First Last Title Work Phone Cell Phone Email Address Information for Each of the Victims How many victims do you need to report?* 12345 Victim #1 Information Victim #1 Name* First Last Victim #1 Job Title* What was the employee doing just before the incident occurred?* What was the injury or illness?* What object or substance directly harmed the employee? Check all that apply:* Fatality Hospitalized Amputation Loss of Eye COVID-19 Corrective Action(s)* Hold Control (CTRL) key to select more than one action. Employee TrainingSupervisor/Management TrainingEngineering ControlsFacility or Equipment Inspection/MaintenanceSignage/LightingShutdown/Lock out EquipmentOther Victim #2 Information Victim #2 Name First Last Victim #2 Job Title* What was the employee doing just before the incident occurred?* What was the injury or illness?* What object or substance directly harmed the employee? Check all that apply:* Fatality Hospitalized Amputation Loss of Eye COVID-19 Corrective Action(s)* Hold Control (CTRL) key to select more than one action. Employee TrainingSupervisor/Management TrainingEngineering ControlsFacility or Equipment Inspection/MaintenanceSignage/LightingShutdown/Lock out EquipmentOther Victim #3 Information Victim #3 Name First Last Victim #3 Job Title* What was the employee doing just before the incident occurred?* What was the injury or illness?* What object or substance directly harmed the employee? Check all that apply:* Fatality Hospitalized Amputation Loss of Eye COVID-19 Corrective Action(s)* Hold Control (CTRL) key to select more than one action. Employee TrainingSupervisor/Management TrainingEngineering ControlsFacility or Equipment Inspection/MaintenanceSignage/LightingShutdown/Lock out EquipmentOther Victim #4 Information Victim #4 Name First Last Victim #4 Job Title* What was the employee doing just before the incident occurred?* What was the injury or illness?* What object or substance directly harmed the employee? Check all that apply:* Fatality Hospitalized Amputation Loss of Eye COVID-19 Corrective Action(s)* Hold Control (CTRL) key to select more than one action. Employee TrainingSupervisor/Management TrainingEngineering ControlsFacility or Equipment Inspection/MaintenanceSignage/LightingShutdown/Lock out EquipmentOther Victim #5 Information Victim #5 Name First Last Victim #5 Job Title* What was the employee doing just before the incident occurred?* What was the injury or illness?* What object or substance directly harmed the employee? Check all that apply:* Fatality Hospitalized Amputation Loss of Eye COVID-19 Corrective Action(s)* Hold Control (CTRL) key to select more than one action. Employee TrainingSupervisor/Management TrainingEngineering ControlsFacility or Equipment Inspection/MaintenanceSignage/LightingShutdown/Lock out EquipmentOther Email This field is for validation purposes and should be left unchanged.
