Grain Bin Entry Incident Report Form
Date of Incident
Time of Incident
Location
Bin Number/ID
Reported By
Name(s) of Person(s) Involved
Contact Information
Job Title/Role
Supervisor Name
Type of Incident
Near Miss
Injury
Fatality
Property Damage
Other
Description of Incident
Immediate Action Taken
Equipment Involved
Rescue Performed?
Yes
No
Was PPE Used?
Yes
No
Witness Names
Corrective/Preventive Actions
Follow-Up Notes