Information
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Employee
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Date of Injury:
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Person notified of injury:
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Photo of Injury:
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Photo of Area Where Injury Occured:
Employee Information
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Name of Injured Employee
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Employee I.D.:
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Date and Time of Report:
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Location of Injury:
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Length of Time With Brandt
- 0 - 3 Months
- 3 - 6 Months
- 6 Months - 1 Year
- 1 - 2 Years
- 3 - 4 Years
- 5 or More Years
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Employee's Home Address:
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City:
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State:
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Zip Code:
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Employees Home Phone Number:
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Date of Birth:
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Trade:
- Mechanical Service
- Electrical
- Sheet Metal
- Plumbing / Piping
- Commissioning
- Office
- Other
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Length of Time in Trade:
- 0 - 3 Months
- 3 - 6 Months
- 6 Months - 1 Year
- 1 - 2 Years
- 3 - 4 Years
- 5 or More Years
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Classification
- Classified Worker
- Mechanic
- Helper
- Apprentice
- Journeyman
- Foreman
- Superintendent
- PAT
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Journeyman / Apprentice Working With:
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Foreman:
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Superintendent:
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General Superintendent:
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Project Manager:
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Witnesses / Classifications
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Witness(es) Phone and Address
Treatment Information:
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Witnesses Names, Addresses,
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Did Employee Receive Medical Attention?
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If Yes, Where?
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Treating Doctors Name:
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Describe Treatment Received:
Accident Information:
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Is This a Late Report?
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If Yes, Why?
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Job Name:
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Job Number:
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Is This a CCIP or OCIP Job?
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If Yes, Who Manages the Program?
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Description of Injury:
- Fall
- Strain
- Cut
- Burn
- Struck By
- Slip / Trip
- Electrical Shock
- Broken Bone
- Pinch
- Eye Injury
- Insect Bite
- Heat Related
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If Other, Explain Here:
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Body Part Affected:
- Head
- Face
- Ear
- Neck
- Shoulder
- Arm
- Hand
- Wrist
- Fingers
- Leg
- Knee
- Ankle
- Foot
- Toes
- Other: Explain Below
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If Other, Explain Here:
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Severity:
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How did the accident occur?
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What contributed to the accident?
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Any Other Employees Involved?
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Names / Classifications of Other Employees Involved:
Working Conditions:
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Phase of Job
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Day of Week:
- Monday
- Tuesday
- Wednesday
- Thursday
- Friday
- Saturday
- Sunday
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Time of Injury:
- Before 6AM
- 6AM - 8AM
- 8AM - 11AM
- 11AM - 1PM
- 1PM - 3:30PM
- 3:30PM - 5:30PM
- After 5:30PM
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Temperature at Time of Accident:
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Weather Conditions:
- Sunny
- Snow
- Ice
- Rain
- Windy
- Dry
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Current Work Schedule:
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Work Schedule in Past Month:
Corrective Actions:
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What Corrective Action(s) Were Taken After Accident?
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What Further Actions Are Still Needed?
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Planned Completion Date:
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Individual Responsible To Complete Corrective Action:
Signatures:
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Employee:
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Foreman:
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Superintendent:
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Safety Coordinator: