C2SC First Report

• First Report

• AWS

• SMI

• SER

• STS

• Job Name

• Location
  Address

• Client / General Contractor

• Conducted on

  Date

• Prepared by

• Fill out the information below to the best of your knowledge. This will help your supervisors with the initial incident investigation report. If any of the questions below do not apply to the incident being reported, put "N/A" in the given spaces.

General Incident Information

• Date & Time of Incident

  Date

• Type of Incident

  Select Injury Near Miss Property Damage

  • Injury
  • Near Miss
  • Property Damage

• Specific Incident Location

• Describe the incident (who, what, when, where, how?)

Injury Information

• Injury Type

• Name of Employee

• Phone Number

• Occupation

  Select Bricklayer Glazier Ironworker Laborer Operator

  • Bricklayer
  • Glazier
  • Ironworker
  • Laborer
  • Operator

• Age

• Years Employed?

• EMS Notified?

  Yes

  No

• Has the injured employee been taken to a clinic/hospital?

  Yes

  No

• Clinic Name & Location