Information
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Brief Description and Location
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Prepared by
Project Information
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Project Name
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Allied Project Manager
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Allied Site Supervisor
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Has Owner or Client been Notified?
Worker Involved or Injured
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Employee Last Name
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Employee First Name
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Phone Number
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Date of Birth
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Date of Incident or Injury
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Time of Incident or Injury
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Job Title
- Tuttle Construction
- Degen
- RD Jones
- RMF
- Sidney Electric
- Superior Air Handling
- Harris Superior CA
- Harris Intermountain
- Wasatch Controls
- RM Thornton Mechanical
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Age
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Incident Classification
- Incident Only
- Near Miss
- Medical Visit Only
- First Aid
- Recordable
- Illness
- Lost Time
- N/A
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Number of Restricted Days (Maximum 180)
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Number of Lost Time Days (Maximum 180)
Description of Injury/Illness?
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Describe the Event in Detail
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Type of Injury
- Sprain/Strain
- Fracture
- Laceration
- Foreign Body
- Burn
- Puncture
- Inhalation
- Abrasion
- Contusion
- Electric Shock
- Thermal Injury
- Bruise
- Concussion
- Amputation
- Chemical Exposure
- Crush
- Insect Sting/Bite
- Hernia
- Rash
- Allergy
- N/A
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Photo(s) of Incident Site
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Body Part Injured
- Head
- Eye
- Ear
- Nose
- Mouth
- Teeth
- Face
- Neck
- Hip
- Chest
- Stomach
- Groin
- Back
- Arm
- Hand
- Finger
- Leg
- Knee
- Ankle
- Foot
- Toe
- N/A
- Body Trunk
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Left or Right Side, Front or Back, Top or Bottom
- Left Side
- Right Side
- Front Side
- Back Side
- Top
- Bottom
- N/A
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Type of Event
- Striking Against
- Struck By
- Caught In or Between
- Stepping On
- Stumbling
- Slip
- Trip
- Fall
- Lifting
- Bending
- Twisting
- Stress
- Pushing
- Pulling
- Jumping
- Motor Vehicle
- Ingestion
- Absorption
- Inhalation
- N/A
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Agency of Event
- Vehicle
- Power Tools
- Animal/Insect
- Biological Agent
- Objects
- Buildings
- Furniture
- Heat Stress
- Chemicals
- Radiation
- Mobile Equipment
- Hand Tools
- Materials
- Equipment
- Structure
- Surfaces
- Sunburn
- Frostbite
- Stress
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Was there any damage to equipment?
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What was the equipment or property?
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Photos of damaged equipment or property.
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Estimated of cost to repair/replace equipment or property.
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Was a post-incident drug test completed?
Medical Treatment Information
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Where was medical treatment provided?
- First Aid
- Occupational Clinic
- Emergency Room
- Private Physician
- N/A
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Name of Treating Medical Service Provider (if Offsite Medical, Clinic, or ER)
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Address of Clinic or Emergency Room
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Clinic or Hospital Phone Number
Cause or Causes
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Select the Cause or Causes
- Inadequate Instruction
- Inadequate Workspace
- Assistance Unavailable
- Rushing
- Eyes Not on Task
- Fault of Equipment
- Lack of Attention
- Equipment Unavailable
- Frustration
- Mind Not on Task
- Poor Storage
- Poor Access
- Incorrect Method
- Fatigue
- Line of Fire
- Weather
- Terrain
- Work Practices
- Complacency
- Balance/Grip
Incident Statements
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Injured Employee Statement
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Employee Statement (describe incident in own words) What happened? How did it happen?
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Photos of Incident Scene
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Employee Signature
Witness Statement
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Witness Statement (describe incident) Who, What, Where, When, Why, How. Be Specific, No Opinions.
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Witness Signature
Preventive/Corrective Actions
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Corrective Action Required:
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When should this action be completed by?
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Who Is responsible to oversee this action?
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Corrective Action Required:
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When should this action be completed by?
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Who Is responsible to oversee this action?
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Corrective Action Required:
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When should this action be completed by?
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Who Is responsible to oversee this action?
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Long Term Action Required:
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When should this action be completed by?
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Who is responsible to oversee this action?
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Long Term Action Required:
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When should this action be completed by?
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Who is responsible to oversee this action?
Training Required?
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Please indicate if training is required and the type required.
- Yes - Orientation
- Yes - Task Specific
- Yes - Area Specific
- No
Disciplinary Action?
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Please select the appropriate response
- Is Required
- Is Not Required
- Unknown At This Time
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Please indicate what disciplinary action if any
Accident Investigation Completed by:
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Signature of person completing this investigation.
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Investigation completed
Follow-up Investigation
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Is a follow-up Investigation required?
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Has a follow-up investigation been completed?
