Barnard First Report of Incident - duplicate

• Incident Title

• Job Name and Number

• Superintendent

• Project Manager

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel Involved

• What Type of Incident Occured

  Personal Injury

  Third Party Incident

  Equipment Damage

Employee Information

• Employee Name

• Employee Number

• Employee Date of Birth

• Supervisor

• Marital Status

  Single

  Married

  Divorced

• Occupation

  Select Laborer Operator Welder Helper Teamster Foreman / Super PM/Engineer

  • Laborer
  • Operator
  • Welder
  • Helper
  • Teamster
  • Foreman / Super
  • PM/Engineer

• Date Hired

  Date

• Gender

  Male

  Female
• Employee Current Address
  Address
• Employee Permanent Address
  Address

• Employee Phone Number

INJURY INFORMATION

• Date of Injury and Time of Injury

  Date

• Time Shift Started

  Date

• Date and Time Reported

  Date

• Person Employee Reported To

• Work employee was performing when injured

• Describe in detail how the injury occurred, and give cause(s)

• Describe location of accident

• Photos of Location

  Media

• List any tools/equipment involved

• Hazardous Material(s) involved in incident?

  YES

  NO

• Trade Name of Product

• Other Issues related to the incident (if any)

• Weather Conditions at time of Injury

  Select Clear Sunny Windy Rain Snow Fog

  • Clear
  • Sunny
  • Windy
  • Rain
  • Snow
  • Fog

• Employee using PPE provided

  Yes

  No

  N/A

• Additional PPE required?

  YES

  NO

Employee Information

• Employee Name

• Employee Number

• Employee Date of Birth

• Supervisor

• Marital Status

  Single

  Married

  Divorced

• Occupation

  Select Laborer Operator Welder Helper Teamster Foreman / Super PM/Engineer

  • Laborer
  • Operator
  • Welder
  • Helper
  • Teamster
  • Foreman / Super
  • PM/Engineer

• Date Hired

  Date

• Gender

  Male

  Female
• Employee Current Address
  Address
• Employee Permanent Address
  Address

• Employee Phone Number

Incident Information

• Type of Damage

  Property Damage / Loss

  Utility Damage / Loss

  Third Party Injury

  Environmental Release

  Other

• Type of Incident

• Date and Time of Incident

  Date
• Location of Incident
  Address

• Company Equipment Involved

• Unit #

• Date and Time Reported

  Date

• Reported By

• Describe the Incident in Detail

• Injuries Related to Incident

  YES

  NO

• Who

• Extent of Injuries

• Owner of Damaged Propery

• Owners Address
  Address

• Pictures

  Media

• Type of Property Damaged: Year, Make, Model

• Extent of Property Damaged

• Emergency / Remedial Actions taken to Control and/or Mitigate Effects of Incident

• Employees / Personnel Involved in Incident Response or Cleanup

• Employees Address/Phone

• Weather Conditions

  Select Clear Sunny Windy Rain Snow Fog

  • Clear
  • Sunny
  • Windy
  • Rain
  • Snow
  • Fog

• SDS Information

  Select Yes No Provided NA

  • Yes
  • No
  • Provided
  • NA

Authorities/Agencies at Incident

• List agencies / Authorities Contacted and or at the site

  Select Local Police Sheriff Department State Patrol Fire Department Paramedics OSHA Local Health Dept EPA Other

  • Local Police
  • Sheriff Department
  • State Patrol
  • Fire Department
  • Paramedics
  • OSHA
  • Local Health Dept
  • EPA
  • Other

• Other Agency

• Case Number

• Name and Phone Number of Person with Agency

Utility Damage/Loss Information

• Name of Utility Owner

• Original Locate Ticket Number

• Damage Ticket Number

• Utility Company Contact Name / Title / Phone Number

• Type of Utility Damaged

  Select Telephone Electrical Gas Water Sewer Cable TV Storm Fiber Other

  • Telephone
  • Electrical
  • Gas
  • Water
  • Sewer
  • Cable TV
  • Storm
  • Fiber
  • Other

• Other Type of Utility

• Utility Location

  Above Ground

  On Surface

  Below Ground

  Other

• Other

• Is Locate Ticket Current

  Yes

  No

  N/A

• Date of Last Locate

  Date

• Were Utility Markings Visible in Area

  Yes

  No

  N/A

• Photos of Markings

  Media

• Were Utility Markings Accurate

  Yes

  No

  N/A

• Measurements Taken

  Yes

  No

  N/A

• Photos

  Media

Employee Information

• Employee Name

• Employee Number

• Employee Date of Birth

• Supervisor

• Marital Status

  Single

  Married

  Divorced

• Occupation

  Select Laborer Operator Welder Helper Teamster Foreman / Super PM/Engineer

  • Laborer
  • Operator
  • Welder
  • Helper
  • Teamster
  • Foreman / Super
  • PM/Engineer

• Date Hired

  Date

• Gender

  Male

  Female
• Employee Current Address
  Address
• Employee Permanent Address
  Address

• Employee Phone Number

Equipment Information

• Equipment Description

• Equipment Number

• Rented or Owned

  Rented

  Owned

• Date of Equipment Damage

  Date

• Reported To

• Date and Time Damage Reported

  Date

• Damage Repair Cost Estimate $

• Was an Injury Possible

  Yes

  No

• Describe in Detail the Equipment Damage, All Involved Parties, Location and Circumstances , Body or Other Damage

• Photos

  Media

• Police Report Attached

  Yes

  No

  N/A

• Photo of Police Report

  Media

• PREVENTIVE MEASURES TAKEN TO STOP REOCCURENCE

Witness Information

Witness

• Names of Witnesses

• Other Document or Statements Related to Incident

  Media

• Witness Statement

• Signature of Witness

  Sign

Signatures

• Supervisor

  Sign

• Project Superintendent

  Sign

• Project Manager

  Sign

• Safety Manager

  Sign