SAFETY INCIDENT REPORT
LOCATION
*
Please Select
Accounting - Corp General
Accounts Payable
Accounts Receivable
Air Entangling
Antioch Finishing
Antioch Home
Antioch Plant 1
Antioch Plant 2
Antioch Other
Antioch Road
Antioch Tufting
Architectural Representative
Ashland
Asselin Np
Atlanta
Aurora
Axminster Mending
Axminster Weaving
Backing
Backsizing
Baton Rouge
BCF
Beam Material Prep
Beam Tufting
Beaming
Beaming Tufting
Beck Dye
Bennettsville
Bigelow
Binding
Blending
Body Prep
Boilerhouse
Bolingbrook
Bound Rug Binding
Brentwood
Bridgeport Yarn
Bridgeport Extrusion
Bridgeport Home
Buffalo
Builder
Bulk Continuous Filament
Bullnose
Business Process
Calhoun
Calhoun Bcf
Calhoun Corporate Office
Calhoun GHB
Calhoun GHB Delivery Drivers
Calhoun Mfg
Calhoun W Line Dr - Bound Rug
Canada
Caradon
Carding Drafting
Carpet Mfg General
Carpet Tile Cutting
Carpet Tile Manufacturing
Carpet Tile Mfg
Central (AO/MZ)
Central Stock Room
Centralized Routing
Chantilly, VA
Charlotte
Chatsworth
Chatsworth Bcf
Chatsworth Finishing
Chehalis
Claims
Claims - Field Services
Claims - Local
Clay Rd
Clay Rd RDC
Coater
Coating
Coating - Woven Rugs
Coating A
Coating B
Color Compounding
Color Ctr Program
Commerce
Commercial
Commercial MFG
Compensation-Benefits
Conventional Winding
Coppell
Corp Mill Warehousing
Corp Yarn Manufacturing
Corporate - General
Corporate - Operational Hr
Corporate Applications
Corporate Chemical Lab
Corporate Offices
Corporate Record Retention
Cost Accounting
Creative Services
Credit
Creel Material Prep A
Creel Material Prep B
Creel Tufting
Creel Tufting A
Creel Tufting B
Cushion
Cushion Manufacturing
Customer Compliance
Customer Service
Customer Service - Admin
Customer Service Operations
Customer Svc
Cut Order
Cut Order - Carpet
D8
Dallas
Dallas Builder Distribution Center
Daltile
Daltile Corporate
Dal-Tile Corporate Office
Danville
Delivery Exp
Densifying
Des Moines
Design
Dickson
Distributed
Dm - Al-Cen Tn
Dm - Ar
Dm - Atl Metro Builder
Dm - Az-So Nv
Dm - Cent - So Al
Dm - Cent Ca
Dm - Cincinnati-Ky
Dm - Columbus Oh
Dm - Dfw
Dm - Dfw-Builder-Multi
Dm - E Wa-No Id
Dm - East Tx
Dm - Ga
Dm - Hawaii
Dm - Ia-Sd-Nd-Wi
Dm - Indiana
Dm - Metro Ny-Long Isl-W Ct
Dm - Mi
Dm - Nc Metro Markets
Dm - Ne Oh
Dm - Ne-Kansas City-Mo
Dm - New England- East Ct
Dm - No Cent Atlanta
Dm - No Cent Il
Dm - No Chicago Land
Dm - No New England
Dm - No Nj-Lower Ny State
Dm - No Tx-Ok
Dm - North Fl
Dm - Nw Tx-Nm
Dm - Ok-E Tx
Dm - S Diego-Imperial-S La
Dm - San Diego
Dm - So Chicago Land
Dm - So Tx
Dm - South Fl
Dm - Specification
Dm - St Louis-E Mo
Dm - Sw Fl
Dm - Upstate Ny-Vt
Dm - W - No Mi
Dm - W Or-Sw Wa
Dm - W Tx-Nm
Dm - Wv-Va-Dc
Dm-Chicago-Wisconsin
Dm-North Florida
Dry Clean
Duvall Miles
Duvall Miles Seaming
Duvall Road
Dyeing
Dyeing - Yarn
Earth City
East Sales Leader
Eden Rug Mill
Eden Service Center
Edmond Street
El Paso
Eldersburg Annex
Eldersburg Customer Service
Eldersburg Inventory Control
Eldersburg Maintenance
Eldersburg Picking
Eldersburg RDC
Eldersburg Receiving
Eldersburg Shipping
ELP Audit
ELP Body Prep
ELP Facility Maintenance
ELP Glaze Lines
ELP Glaze Prep
ELP Kilns
ELP Presses
ELP Shipping and Receiving
ELP Sorting
Employee Relations Benefits
Engineering Services
Environmental Services
Eton Tufting
Eton
Eton Air Entanglement
Eton Warehouse
Eton Color
Eton Tufting
Eton Warehouse
Executive
Executive - Corporate
Export Canada Home Office
Extrusion
Extrusion - Backing
Extrusion 2
Extrusion 3
Extrusion Ae Svcs
Extrusion Plant 2
Extrusion/Bulk Continuous Filament Plant 1
EZ Tile
Fayette
Field Claims Svc
Fin Goods Warehouse-Shipping
Finance
Financial Mfg Accounting
Financial Systems And Process
Finished Goods Whse Shipping
Finishing
Flooring
Flooring Admin Corporate
Flooring Admin Group
Flooring Administration
Flooring Employee Relations
Floorscapes
Florence
Florence RDC
Flower Mound
Fontana
FYT Crushing
FYT Forming
FYT Setting
FYT Slabs
FYT Sorting
FYT Unloading
FYT Warehouse
Garner-Pergo
Garnetting
Garnetting - Mfg Services
General Administration
Gettysburg
Gettysburg Facility
Glasgow
Glaze Line
Glaze Lines
Glaze Prep
Glen Burnie
Global Sourcing
Glue Line
Glue Seal
Goodwill Drive
Graphics
Green Street
Green Street Engineering
Green Street Logistics
Greenville
Greenworks
Grinding
Gsm 034
Gsm 050
Gsm 052
GTY Facility Maintenance
GTY Mounting
GTY Shipping and Receiving
GTY Trim Mounting
Guillotine
Hard Surface Florida
Hard Surface Mfg
Hard Surface Mfg Corporate
Hard Surface North Central
Hard Surface Northeast
Hard Surface South Central
Hard Surface Southeast
Hard Surface Southwest
Hayward
HCS
Heat Set (Spun)
Heat Set Bcf
Highland Road
Highland Tufting EOL
Hillsville
Hillsvillle Backing
Holden
Home
Home Corporate - General
Home Depot - Us
Home Office"
Honolulu
Hospitality
Hospitality Corporate
Houston
H-S Dfw Builder-Multi
Huffaker
Human Resources
Image Transfer
Imaging Services
Indianapolis
Industrial Engineering
Industrial Park
Industrial Park Yarn
Internal Audit
International
International S America
International Selling
International Selling Corporate
Intl Supply Chain -Sou
Is Administration
IVC-CV
IVC-LVT
IVC-Distribution
Johnstown
Kansas City (Shawnee)
Karastan
Karastan Rug Division
Kearny
Kent
Kiln
Knitting
Kustercolor
La Mirada
Lab
Landrum
Large Host Systems
Laurel Hill
Laurens Park
Lavender
Layout Critique
Lees
Legal
Lewisport
Lincolnway East
Lockbourne
Logistics
Logistics - Freight Moves
Logistics - Safety
Logistics North GA
Lowes - Us
LSP Crushing
LSP Drying
LSP Glaze
LSP Kiln
LSP Milling
LSP Packing
LSP Presses
LSP Setting
LSP Shipping and Receiving
LSP Sorting
LVT
LWE East Press
LWE Facility Maintenance
LWE Kiln
LWE Mixing
LWE Trim Press
LWE West Press
Lyerly
M - Ny State
Maintenance
Manufacturing
Manufacturing Admin
Manufacturing Services
Marine Drive
Marketing
Master Data Management
Mat Packing
Mcfarland
Mexicali, Pad
Mexicali, Daltile
Melbourne
Melt Spinning
Memphis
Mending
Mendota Heights
Mfg Product Development
MHC Corporate
Miami (Pembroke Park)
Mid Atlantic
Mid Range
Mid-Atlantic
Midsouth
Mid-South
Midway
Midwest
Mill Administration
Mill Information Services
Mill Warehouse Admin
Mill Warehouse Maintenance
Milledgeville
Mo6-Higland
Mohawk
Mohawk Corporate
Mohawk Corporate Office
Mohawk Flooring Center
Mohawk Home
Mohawk Home Centers
Mohawk Home Manufacturing
Mohawk Industries
Mohawk Team Svcs (Commercial)
Mohawk University
MON Floor Tile
MON Fritas
MON Larger Unit Wall Tile
MON Mosaic
MON RDC
MON Refractories
MON Salamanaca
MON Sample Board and Skin Pack
MON Staff
MON Wall Tile
Monterrey
Morrisville
Mosaics
MSK Audit
MSK Body Prep
MSK Facility Maintenance
MSK Glaze Lines
MSK Glaze Prep
MSK Kilns
MSK Presses
MSK Shipping and Receiving
MSK Sorting
MT Gilead
Multicolor
Muskogee
Muskogee Customer Service
Muskogee Inventory Control
Muskogee Maintenance
Muskogee Picking
Muskogee RDC
Muskogee Receiving
Muskogee Shipping
Nashville
National
Nc Metro Markets Builders
Ne Oh-Pa
Network - Telecommunications
Network Server Support
New York Metro
Non Woven
North Central
North Ga Conveyor
Northeast
Northeast Stone Center
Northwest
Oak River North- Extrusion
Oak River North- Yarn
Oak River South
Occupancy
Ohio Valley
Oklahoma City
Olean
Ontario Customer Service
Ontario Inventory Control
Ontario Maintenance
Ontario Picking
Ontario RDC
Ontario Receiving
Ontario Shipping
Operations Administration
Orangeburg
Orlando
Outside Pad
Pad Manufacturing
Payroll
PE Wash
Peachtree
Pellitizer
Pensacola
Performance General-Special Goods
Phelps Rd
Phoenix
Pick - Pack
Pieces
Pile Beaming
Pilot Plant
Pilot Plant -R - D
Pine Street
Pittsburgh
Planning (Floor Layout)
Precision Winding
Press
Pricing
Pricing System
Printing
Private Otr
Process Reliability
Product Design
Product Development
Product Management
Product Market Development
Product Mgmt - Floor Mat
Production Control
Production Control - Durkan
Production Planning
Production Strike Off
Purchasing
Quality Control
Raleigh, NC Warehouse
R-D - Floor Mat
Re Transportation Expense
Recycling
Reeling
Reg Transportation Expense
Region - Mid-Atlantic
Region - Midwest
Region - Northeast
Region - Northern Pacific
Region - Southeast
Region - Western
Regional Distribution Centers
Regional Office
Reinspect Rework
Reinspect-Rework
Remote Warehouse Shipping
Remote Warehouse-Shipping
Remote Warhouse Shipping
Remote Whse Shipping
Research and Development
Reshear
Residential MFG
Residential National Accounts
Residential Planning
Roanoke
Robot Swatch Line
Rocky Mountain
Rocky River
Rubber Mats - Die Cut
Rubber Mats - Flocking
Rubber Mats - Moulding
Rug Coating
Rug Cutting
Rug Dye House
Rug Fabrication
Rug Finishing
Rug Greige Sew
Rug Service Department
Rug Ship Warehouse
Rugs
Rvp
Rvp R01
Rvp R02
Rvp R05
Rvp R06
Rvp R07
Rvp R10
Sales-Commercial
Sales-Residential (BMF)
Sales-Residential (Hard)
Sales-Residential (Soft)
Sales-Marketing
Sales-Business Units
Sales-Planning-System Migrate
Salt Lake City
Sample Administration
Sample Department
Sample Distribution
Sample Labeling
Sample Manufacturing
Sample Restocking
Samples MFG
San Antonio
San Francisco Bay
Sawline
Scatter Finishing
Scheduler
SCP- Central Plains
Screens
Se Oh-Wv-Ky
Seaming
Security
Selection
Selling
Selling Admin - Vp
Set Packing
Setting
Ship - Receive
Shipping - Receiving
Shipping And Receiving
SID
Site Management Services
Skein Dye
Skein Dyed Winding
Sma-Mid Atlantic
Sms
Soft Surface Florida
Soft Surface Mid Central
Soft Surface North Central
Soft Surface Northeast
Soft Surface Northwest
Soft Surface South Central
Soft Surface Southeast
Soft Surface Southwest Coast
Solid Dye Range
Sourced Product Management
South Hamilton Distribution
South Industrial - Mats
South Nj- Pa# 536
South Tx Builder -Multi
Southeast
Southeast Customer Acct Service
Southern Cal
Southern Cal Region Sales
Southwest
Space Pad Dye
Space-Pad Dye
SPC
Special Order Contract Analyst
Special Order Contract Sim
Special Projects
Spectronic
Spinning
Ssec
Stockholder Relations - Report
Strike Off Office
Strip Table
Strongsville
Style - Design
Style And Design
Sugar Valley
Summerville BCF
Summerville Greenworks
Summerville Recycling
Sunnyvale
Sunnyvale Customer Service
Sunnyvale Inventory Control
Sunnyvale Maintenance
Sunnyvale Picking
Sunnyvale RDC
Sunnyvale Receiving
Sunnyvale Shipping
Superba Dye Line
Supply Chain
SVL 1
SVL 2
SVL 3
Swatch Bevel
System Engineering
Tapistron Tufting
Tax
Technical Services
Texoma
Thomasville
Threading
Tifton
Tile Extrusion
Tops
Torrington
Transportation
Treadwell
Treasury
Trim - Label
Tufted Finishing - Calhoun
Tufting
Tufting - Rug
Tufting Support A
Tufting Support B
Tufting-Rugs
Twisting - Reeling
Twisting (Spun)
Twisting Bcf
Unilin
Unilin Corporate
Union Grove DC
Union Grove Finishing
US Manufacturing
Utility
Van De Wiele Loom
Virgil Drive
Wall Street
Walpole
Warehouse-Florida
Warehouse-Mid Atlantic
Warehouse-Midwest
Warehouse-North Central
Warehouse-Northeast
Warehouse-Ohio Valley
Warehouse-Southeast
Warehouse-Southwest
Warehouse-West
Warping
Washing
Waste Stream Management
Water Treatment
Waukesha
Weaving
Weaving - Backing
Weaving - Secondary Backing
Weaving - Support
Weaving - Woven Rugs
West Line Bound Rug
Westampton (Moorestown)
Western (AO/MZ)
Western Sales Leader
Winding
Winding - Yarn
Wixom
Wms-Dist-Shipping-Logistics
Work from Home-Canada
xClosed Locations
Yarn Manufacturing - Backing
Yarn MFG
Yarn Prep Beaming
Yarn Prep-Rugs
ORGANIZATIONAL LEVEL
*
Please Select
Contractor
Leadership Team Member
Manager
Supervisor
Team Member
Temporary
INJURY STATUS
*
Please Select
Near Miss
First Aid
Recordable
Loss Time
DEPARTMENT
*
Please Select
Administrative
Engineering
Maintenance
Operation
Sales
SHIFT
*
Please Select
Friday-Day Shift
Friday-Night Shift
Monday-Day Shift
Monday-Night Shift
Saturday-Day Shift
Saturday-Night Shift
Sunday-Day Shift
Sunday-Night Shift
Thursday-Day Shift
Thursday-Night Shift
Tuesday-Day Shift
Tuesday-Night Shift
Wednesday-Day Shift
Wednesday-Night Shift
EXACT LOCATION
*
INCIDENT TITLE
*
TIME EMPLOYEE BEGAN WORK
*
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12
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Hour
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05
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15
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35
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45
50
55
Minutes
AM
PM
AM/PM Option
TIME OF OCCURENCE
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2
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5
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11
12
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Hour
00
05
10
15
20
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30
35
40
45
50
55
Minutes
AM
PM
AM/PM Option
DATE OF OCCURRENCE
*
-
Month
-
Day
Year
Date Picker Icon
EMPLOYEE'S NAME
*
First Name
Last Name
EMPLOYEE'S ID
*
DATE OF BIRTH
*
-
Month
-
Day
Year
Date Picker Icon
DATE OF HIRE
*
-
Month
-
Day
Year
Date Picker Icon
EMPLOYEE ADDRESS
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
GENDER
*
Please Select
MALE
FEMALE
SUPERVISOR
*
WITNESS(ES) NAME (ATTACH STATEMENTS)
*
NATURE OF INJURY / ILLNESS
*
Please Select
Amputation
Bite/Sting
Bruise/Contusion
Burn/Hot/Cold/Chemical
Concussion/Unconscious
Cut/Laceration/Puncture
Disorders Due to Physical Agent
Disorders/Repeated Trauma
Electric Shock
Exhaustion/Heat Stroke
Foreign Body/Sliver/Chip/Dust
Fracture/Crush/Dislocated
Internal injury/Hernia/Heart
Loss of Senses/Faculties
Lung Problems/Dust-Related
Lung Problems/Toxic Agent
Other/Not Listed
Poisoning
Puncture
Scrape/Scratch/Abrasion
Skin Disease/Disorder
Sprain/Strain/Torn
Suffocation/Drowning
Lift Truck / Property Damage
IS THE EMPLOYEE AMT QUALIFIED
*
YES
NO
PART OF BODY INJURED
*
Please Select
Abdomen
Ankle
Back-Muscles
Back-Skeletal/Nervous
Buttocks
Chest/Ribs
Ears
Elbow
Eyes
Face
Finger
Foot
Forearm
Groin
Hand
Heart
Hip
Knee
Mouth/Teeth
Neck
No part of body was injured
Nose
Scalp
Shin, Calf
Shoulder
Skull
Thigh
Toe
Upper Arm
Whole Arm
Whole Head
Whole Leg
Whole Torso
Wrist
SOURCE
*
Please Select
Bit-stung
Caught in-on-between
Cutting-sawing
Exposure-contact
Fall-elevated surface
Lifting
N/A
Property damage
Push-pull-carry
Repetitive Motion
Slip trip fall
Struck against
Struck by
Vehicle related
WAS A DRUG AND ALCOHOL TEST PERFORMED?
*
Please Select
N/A
No
Yes
WAS THE INJURY REPORTED TO WORKER COMPENSATION AT 1-800-362-0000 WITHIN 24 HOURS OF THE EVENT?
*
Please Select
N/A
No
Yes
INCIDENT DESCRIPTION:
*
RESULT OF DUTIES?
*
Please Select
No
Yes
NAME OF PHYSICIAN OR OTHER HEALTH CARE PROFESSIONAL:
*
WAS EMPLOYEE TREATED IN AN EMERGENCY ROOM?
*
Please Select
No
Yes
WAS EMPLOYEE HOSPITALIZED OVERNIGHT AS AN IN PATIENT?
*
Please Select
No
Yes
HOW DID THE INJURY OCCUR? * DESCRIBE THE INJURY OR ILLINESS.
*
WHAT WAS THE EMPLOYEE DOING JUST BEFORE THE INCIDENT OCCURRED?
*
WHAT OBJECT OR SUBSTANCE DIRECTLY HARMED THE EMPLOYEE?
*
THE FOLLOWING FIELDS ARE RELATED TO INCIDENT INVESTIGATION.
ACTION TAKEN (INTERIM AND FINAL)
*
INVESTIGATED AND PREPARED BY: (LIST NAMES OF INVESTIGATION TEAM)
*
UPLOAD WITNESS STATEMENT
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INCIDENT REPORTED BY: ( NAME)
*
DATE REPORTED
*
-
Month
-
Day
Year
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INCIDENT REPORTED BY: (E-MAIL)
*
INCIDENT REPORTED TO: (E-MAIL)
*
CURRENT TIME:
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11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
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