ACCIDENT REPORT - AUTO / EQUIPMENT

• Document No.

• Conducted on

  Date

• Date and Time of the Incident / Accident

  Date

• Client / Site

• Location
  Address

• Driver / Employee Name

• Driver License Number and State

• Current Home Address

• Current Telephone Number

• Position

  Select Laborer Welder Helper Welder Mechanic Foreman Supervisor Manager DOT Driver Operator Line Locator Apprentice Electrician Journeyman Electrician

  • Laborer
  • Welder Helper
  • Welder
  • Mechanic
  • Foreman
  • Supervisor
  • Manager
  • DOT Driver
  • Operator
  • Line Locator
  • Apprentice Electrician
  • Journeyman Electrician

INCIDENT / ACCIDENT INFORMATION

• Yes

  No

  N/A

• Type of Incident / Accident

  Select Fatality Lost workdays - days away from work Lost workdays - days of restricted activity Medical treatment needed First aid needed Near Miss Property Damage Other

  • Fatality
  • Lost workdays - days away from work
  • Lost workdays - days of restricted activity
  • Medical treatment needed
  • First aid needed
  • Near Miss
  • Property Damage
  • Other

• Other, specify

• Describe Incident / Accident

• Equipment Involved

• Nature of Injuries

• Was First Aid Rendered (If yes please describe and list by whom)

  YES

  NO

• Did Injured Leave Job ( If yes where, name of hospital or clinic )

  YES

  NO

• Was Injured Drug Tested ( List comments )

  YES

  NO

WITNESSES

• List Crew Working at the Time of Incident / Accident ( Name, Phone #, Employer)

• Witness Description of Incident

• Witness Description of Incident

CORRECTIVE ACTION

• Corrective Action

• Corrective Action Completed By

  Sign

• Prepared By

  Sign

• Title

• Any Pictures Taken

  YES

  NO