Accident Report

• Employee

• Photo of Injury

  Media

• Photo of Area Injury Occured:

  Media

Employee Information

• Name of Injured Employee

• Employee I.D.:

• Date and Time of Report:

  Date
• Location of Injury:
  Address

• Length of Time With Brandt

  Select 0 - 3 Months 3 - 6 Months 6 Months - 1 Year 1 - 2 Years 3 - 4 Years 5 or More Years

  • 0 - 3 Months
  • 3 - 6 Months
  • 6 Months - 1 Year
  • 1 - 2 Years
  • 3 - 4 Years
  • 5 or More Years

• Employee's Home Address:

• City:

• State:

  Texas

  Oklahoma

  Louisianna

  New Mexico

  Arkansas

• Zip Code:

• Employees Home Phone Number:

• Date of Birth:

• Trade:

  Select Mechanical Service Electrical Sheet Metal Plumbing / Piping Commissioning Office Other

  • Mechanical Service
  • Electrical
  • Sheet Metal
  • Plumbing / Piping
  • Commissioning
  • Office
  • Other

• Length of Time in Trade:

  Select 0 - 3 Months 3 - 6 Months 6 Months - 1 Year 1 - 2 Years 3 - 4 Years 5 or More Years

  • 0 - 3 Months
  • 3 - 6 Months
  • 6 Months - 1 Year
  • 1 - 2 Years
  • 3 - 4 Years
  • 5 or More Years

• Classification

  Select Classified Worker Mechanic Helper Apprentice Journeyman Foreman Superintendent PAT

  • Classified Worker
  • Mechanic
  • Helper
  • Apprentice
  • Journeyman
  • Foreman
  • Superintendent
  • PAT

• Journeyman / Apprentice Working With:

• Foreman:

• Superintendent:

• General Superintendent:

• Project Manager:

• Witnesses / Classifications

• Witness(es) Phone and Address

Treatment Information:

• Witnesses Names, Addresses,

• Did Employee Receive Medical Attention?

  Yes

  No

• If Yes, Where?

• Treating Doctors Name:

• Describe Treatment Received:

Accident Information:

• Is This a Late Report?

  Yes

  No

• If Yes, Why?

• Job Name:

• Job Number:

• Is This a CCIP or OCIP Job?

  Yes

  No

• If Yes, Who Manages the Program?

• Description of Injury:

  Select Fall Strain Cut Burn Struck By Slip / Trip Electrical Shock Broken Bone Pinch Eye Injury Insect Bite Heat Related

  • Fall
  • Strain
  • Cut
  • Burn
  • Struck By
  • Slip / Trip
  • Electrical Shock
  • Broken Bone
  • Pinch
  • Eye Injury
  • Insect Bite
  • Heat Related

• If Other, Explain Here:

• Body Part Affected:

  Select Head Face Ear Neck Shoulder Arm Hand Wrist Fingers Leg Knee Ankle Foot Toes Other: Explain Below

  • Head
  • Face
  • Ear
  • Neck
  • Shoulder
  • Arm
  • Hand
  • Wrist
  • Fingers
  • Leg
  • Knee
  • Ankle
  • Foot
  • Toes
  • Other: Explain Below

• If Other, Explain Here:

• Severity:

  Information Only

  First Aid

  Recordable - No Lost Time

  Lost Time

• How did the accident occur?

• What contributed to the accident?

• Any Other Employees Involved?

  Yes

  No

• Names / Classifications of Other Employees Involved:

Working Conditions:

• Phase of Job

  Underground

  Slab Rough In

  Wall / Overhead Rough In

  Finish Out

• Day of Week:

  Select Monday Tuesday Wednesday Thursday Friday Saturday Sunday

  • Monday
  • Tuesday
  • Wednesday
  • Thursday
  • Friday
  • Saturday
  • Sunday

• Time of Injury:

  Select Before 6AM 6AM - 8AM 8AM - 11AM 11AM - 1PM 1PM - 3:30PM 3:30PM - 5:30PM After 5:30PM

  • Before 6AM
  • 6AM - 8AM
  • 8AM - 11AM
  • 11AM - 1PM
  • 1PM - 3:30PM
  • 3:30PM - 5:30PM
  • After 5:30PM

• Temperature at Time of Accident:

• Weather Conditions:

  Select Sunny Snow Ice Rain Windy Dry

  • Sunny
  • Snow
  • Ice
  • Rain
  • Windy
  • Dry

• Current Work Schedule:

  40 or Less Hrs. Per Week

  41 - 48 Hrs. Per Week

  49 - 60 Hrs. Per Week

  More Than 60 Hrs. Per Week

• Work Schedule in Past Month:

  40 or Less Hrs. Per Week

  41 - 48 Hrs. Per Week

  49 - 60 Hrs. Per Week

  More Than 60 Hrs. Per Week

Corrective Actions:

• What Corrective Action(s) Were Taken After Accident?

• What Further Actions Are Still Needed?

• Planned Completion Date:

• Individual Responsible To Complete Corrective Action:

Signatures:

• Employee:

  Sign

• Foreman:

  Sign

• Superintendent:

  Sign

• Safety Coordinator:

  Sign