Information
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Report date and time
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Report title
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Reporting guard
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Follow-up guard
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Document No.
Shop accident
Damage
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Date/time of accident
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Details of accident
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Contributing factors
- rain
- snow/ice
- sun
- poor lighting
- obstructed view
- distracted
- other (specify below)
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Images
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Guard observations
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If there was a witness, check the box ->
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Witness
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Name
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Badge Number
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Statement
Employee Involved
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Employee
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Employee name
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Badge Number
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Department and supervisor
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Statement
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Drug screen
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Other location
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Alcohol screen
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Other location
Vehicle or mobile equipment (click button on right to add)
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Company vehicle or mobile equipment
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Vehicle Type (truck, crane, forklift, etc.)Driver
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ID number or Tag
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Driver's Name
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Badge or DL number
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Statement
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If there was another occupant in the vehicle, check here ->
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Occupant's name
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Badge or DL number
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Statement
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Non-company owned vehicle or equipment
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Vehicle or equipment description
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ID number or Tag
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Driver's Name
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Badge or DL number
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Phone
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Address
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Statement
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If there was another occupant in the vehicle, check here ->
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Occupant's name
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Badge or DL number
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Address
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Phone
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Statement
Injuries
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If there were injuries, check here ->
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Injured person' name
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Nature of injury
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Treatment
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Other
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Notes
Follow-up
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Additional Info
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Date and time of addition
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Guard
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Additional info
