2025 Incident, Accident, Injury

• Prepared by

  Select

• Report conducted on

  Date

• Was an employee injured?

  Yes

  No

• What type of Incident is being reported

  Select Injury Truck damage Equipment Damage First Report of Injury (documentation only) Theft

  • Injury
  • Truck damage
  • Equipment Damage
  • First Report of Injury (documentation only)
  • Theft

• What is the bumper #

  Select

• What was damaged?

• Enter name of injured employee(s)

• Name of employee(s)

• What was taken? (make, model, # of, etc)

• what is the bumper #

  Select

• enter unlisted bumper #

Incident Details

• Who was this first reported to (GC, Northwest PM, Foreman, Safety)

  GC

  NW PM

  NW Foreman

  Safety

  Safety Culture

• Briefly explain what happened just before the incident

• Briefly explain what happened then

• Is there anything that could have prevented this from happening?

• Any suggestions on how to prevent this from occurring again?

• Include incident pictures here

  Media

• More pictures entered here

  Media

• If a police report was filed, take a picture and add here

  Media

• If a vehicle was involved, take pictures that show license plate, vehicle VIN, Insurance, and Drivers License

  Media

• More pictures added here if needed

  Media

• Pursue estimate of repairs asap, and when obtained, edit this template to be included on this report. Add pictures here.

  Media