Employee Information

  • Accident Date / Time

  • Division:

  • Date report complete

  • Employee name

  • Last four of Social Security no.:

  • Job Title

  • Supervisor

  • Employee home address

  • Employee cell/home phone

  • If auto accident:

  • Watson Electric drivers description of accident:

  • Immediate drug screen performed

Automobile Accident

Automobile Accident

  • Auto accident:

  • Location of accident: street, city, state

  • Intersection if applicable:

  • Type of collision:

  • Photographs of the accident scene:

  • Skid marks made from Watson Electric vehicle:

  • Measurement of skid marks:

  • Skid marks made from other parties involved in accident:

  • Measurements of skid marks:

  • Model and make of Watson Electric vehicle: No., year, make, model

  • Model and make of other vehicles: year, make, model

  • Weather factors:

  • Which driver was effected by the weather:

  • Comments:

Injuries

  • Did injuries occur:

  • Names and phone numbers of those injuries:

  • Were persons injured transported to a medical facility:

  • Mode of transportation:

  • Name of medical facility, address, state and phone number:

Eye witness information:

  • Name address phone cell/home

  • Eye witness description and diagram of accident:

  • Add media

  • Supervisors description and diagram of accident with any unusual findings: illegal substances, no drivers license with driver or attach photo.

  • Add media

  • Recommendations on correct action to prevent similar accidents:

  • Safety representative shall provide transportation for the employee to a drug testing facility. (If this is a DOT recordable accident, drug and alcohol testing must be done within 2 hours).

  • Supervisors signature:

Burn

Burn Incident Report

  • Burn incident report

  • Date and time of Burn incident

  • Type of Burn:

  • Type of burn

  • Location of incident: job site, street, town, state

  • What type of electrical device caused the Burn:

  • Voltage was tested by:

  • What procedures were used to test the voltage?

  • Indicate measurement of voltage:

  • Rubber gloves worn by employee:

  • Glove test date:

  • List protective gear worn by employee:

  • We're rubber blankets used:

  • Rubber blanket test date:

  • We're there burn marks on the employees clothing:

  • Was employee knocked away from or remained connected to electrical force:

  • Photographs of area where incident occurred:

  • Photo

  • NOTE: ANY TOOL BEING USED NEEDS TO BE TURNED INTO THE SAFETY REPRESENTATIVE

Injuries

  • Did injuries occur?

  • Did employee lose consciousness?

  • Names and phone numbers of other injured in the accident:

  • Were persons injured transported to a medical facility:

  • Mode of transportation:

  • Name of Medical Facility, address, state, phone:

Eye witness information:

  • Name address, phone cell/home

  • Eyewitness description of accident or attached photo:

  • Photo

  • Supervisor description and diagram of Burn incident and unusual findings or attach photo:

  • Photo

  • Recommendations on corrective actions to prevent similar accidents:

  • Safety representative shall provide transportation for employee to drug testing facility. (If this is a DOT recordable accident, drug and alcohol testing must be done within 2 hours)

  • Supervisor Signature

Cut Line incident

Cut Line Incident

  • Cut line incident

  • Date / Time line was cut:

  • Type of line cut:

  • Location of cut line street, town, state

  • Intersection if applicable:

  • Was cut line active:

  • Was the cut line located in DOT right of way:

  • Photograph of cut line measured to locate mark with tape measure readable?

  • Photo

Locate information

  • Locate ticket number:

  • Name of person who called for the locate ticket:

  • Was update required for locate ticket?

  • Date of up dated locate ticket:

  • Name and phone number of persons updating the locate ticket:

Other Companies involved in project:

  • Name, address, city, state, phone number:

Injuries

  • Did injuries occur?

  • Names and phone numbers of those injured in the accident:

  • Were injured people transported to a medical facility:

  • Mode of transportation:

  • Name of Medical Facility, address, city, state, phone number:

Eye witness information:

  • Name, address, phone cell/home:

  • Eye witness description of accident or attached photo:

  • Photo

  • Supervisors description and diagram of cut line with unusual findings or attach photo. Show all marks with color description on diagram and note the date and time diagram was made.

  • Photo

  • Recommends on corrective action to prevent similar accidents:

  • Safety representatives shall provide transportation for the employee to drug testing facility. (If this is a DOT recordable accident, drug and alcohol testing must be done within 2 hours.

  • Supervisors signature:

Exposure Incident

Exposure Incident

  • Exposure incident

  • Date / Time of exposure:

  • Location of where exposure occurred: Street, Town, State

  • Were MSDS sheets available:

  • Type of Exposure / Material:

  • Other type of exposure:

  • Was area contaminated and / or isolated:

  • HAZMAT crew called:

  • Photographs of exposure area and materials (attached)

  • Photo

  • Now long was employee exposed to hazardous material:

  • Did employee complain of any symptoms prior to exposure:

  • Describe in detail the employee's symptoms after exposure:

  • Has the employee had a history of similar symptoms / complaints:

  • Were there others working in the exposed area:

  • List names of others working in the exposed area:

  • Were environmental studies made available prior to beginning work:

  • Describe in detail what was being done at the time of exposure:

  • Was information made available covering affects of exposure:

  • If yes describe:

Injuries

  • Did injuries occur:

  • Were persons injured transported to medical facility?

  • Mode of transportation:

  • Name of Medical Facility, address, city, state, phone number:

Eye witness information:

  • Name, address, phone cell/home

  • Eye witness description of accident or attached photo:

  • Photo

  • Supervisors description of exposure and any unusual findings or attached photo:

  • Photo

  • Recommendations on corrective action to prevent similar accidents:

  • Safety representative shall provide transportation for the employee to a drug testing facility. (If this is a DOT recordable accident drug and alcohol testing must be done within 2 hours).

  • Supervisors signature :

Heat stroke, Heat exhaustion, Heart attack

Heat Stroke, Heat Exhaustion, Heart Attack

  • Heat Stoke, Heat Exhaustion, Heart Attack

  • Location of incident: Street, Town, State

  • Time employee arrived at work:

  • Time of event:

  • Signs / Symptoms of event:

  • Medical history of heart disease or stroke:

  • Weather factors:

  • Temperature:

  • Specific description and diagram (attached photo)

  • Photo

Injuries

  • Did injury occur:

  • Were persons injured transported to a medical facility?

  • Mode of transportation:

  • Name address of medical facility:

Eye witness information:

  • Name, Address, phone cell/home:

  • Eye witness description of incident or attached photo:

  • Photo:

Supervisors description of accident:

  • What was the employee doing within 2 hours prior to the medical event occurred:

  • What type of work / activities was employee doing at the time of the medical event:

  • Did employee take any leave prior to the medical event:

  • Could a specific event in the course of employment been the cause of the medical event:

  • If, yes describe:

  • We're there any complaints by the employee prior to the medical event:

  • Describe:

  • Any personnel issues employee was talking about prior to the medical event:

  • If yes, describe in detail:

  • Recommendations on corrective action to prevent similar accident:

  • Safety representative shall provide transportation for the employee to a drug testing facility. (if this is a DOT recordable accident, drug and alcohol testing must be done within 2 hours).

  • Supervisors signature

Lifting or back injury

Lifting/Back injury

  • Lifting/back injury

  • Date / Time of incident:

  • Location: job site, City, State

  • Specific cause of injury:

  • Specific location on back where injury occurred:

  • Chief complaint of pain:

  • Repetitive activity:

  • Treatment:

  • Treating hospital, address of treating facility, physicians name, phone number:

Incident report:

  • Photographs:

  • Add media

  • Description of scene:

  • Complain from employee before accident/incident:

  • Complain from employee after accident/incident:

  • Conditions of floor or stairs, if applicable:

  • Description of what employee was lifting:

  • Inspection and type of shoes employee was wearing:

  • Has employee requested time off before this alleged accident:

  • Was ergonomics applied to the job specifics for this employee:

  • Weather factors: (if outdoors)

  • Other factors:

Eye witness information:

  • Name, address, phone cell/home:

  • Eye witness description of incident and diagram or attached photo:

  • Add media

  • Supervisors description of accident/incident and diagram or attached photo:

  • Add media

  • Recommendations: Supervisor

  • Recommendations: employee

  • Recommendations: equipment

  • Recommendations: environment

  • Safety representative shall provide transportation for the employee to a drug testing facility. (If this is a DOT recordable accident, drug and alcohol testing must be done within 2 hours).

  • Supervisors signature:

Repetitive Trauma

Repetitive Trauma

  • Repetitive Trauma

  • Date/Time of incident:

  • Location where incident occurred: Job site, Address, State

  • Intersection if applicable:

  • Describe the history of exposure to hazardous activity (business and pleasure):

  • Was an ergonomic assessment performed on the work area prior to the incident:

  • Describe full and complete job description:

  • Had employee requested leave prior to the incident:

  • List any known hobbies of employee:

  • Describe the employees daily routine of job, including but not limited to breaks and lunch:

  • Photographs of incident and injury:

  • Photo

  • Did employee complain of any symptoms prior to accident:

  • Describe in detail the employee's symptoms after incident:

  • When did employee begin to complain of symptoms:

  • Has the employee had a history of similar symptoms/complaints:

  • Does the employee have any other health issues:

  • What are these issues:

  • Does the employee follow the safety policies at all times:

  • Explain concerns:

  • Has the employee ever been written up for violations of the safety policy:

  • Were there other employees working in the area:

  • List name of those working in the area:

Injuries

  • Did injuries occur:

  • Were persons injured transported to a medical facility:

  • Mode of transportation:

  • Name of medical facility, address, city, state, phone number:

Eye witness information:

  • Name, address, phone cell/home:

  • Eye witness description and diagram of accident or attached photo:

  • Photo:

  • Supervisors description of accident and unusual finding including but not limited to all employees or attached photo:

  • Photo:

  • Recommendations on corrective actions to prevent similar accidents:

  • Safety representative shall provide transportation for the employee to a drug testing facility. (If this is a DOT recordable accident, drug and alcohol testing must be done within 2 hours).

  • Supervisors signature

Slips and Falls

Slips and Falls

  • Slips and Falls

  • Date/Time of incident:

  • Location where incident occurred, job site, city, state:

  • Describe injury (nature / body part):

  • Treatment:

  • Treatment facility Name, Address, City, State. Physician name and phone number:

Incident report

  • Photographs:

  • Add media

  • Description of scene:

  • Inspection and description of employees shoes:

  • Complaints from employee before the accident/incident:

  • Complaints from employee after the accident/incident:

  • Accident occurred on:

  • Describe:

  • Description of Accident:

  • Weather factors:

  • Temperature:

  • Other factors:

Eye witness information:

  • Name, address, phone cell/home:

  • Eye witness description and diagram of accident/incident or attached photo:

  • Add media

  • Supervisors description and diagram of accident/incident or attached photo:

  • Add media

  • Recommendations: supervisor

  • Recommendations: employee

  • Recommendations: equipment

  • Recommendations: environment

  • Safety representative shall provide transportation for employee to a drug testing facility. (If this is a DOT recordable accident, drug and alcohol testing must be done within 2 hours).

  • Supervisors signature

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