Title Page
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Company Name
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Job Name
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Job Location
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Conducted on
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Incident Type
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Prepared by
Near Miss
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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, leave the space blank or type "N/A".
General Incident Information
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Date & Time of Incident
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Time Work Started
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Specific Incident Location
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Witnesses?
Near Miss
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List person(s) involved
Incident Description
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Describe clearly what took place. Include materials, equipment, and environmental conditions involved in the incident. Provide information that led up to the incident. Include photos by selecting "Add Media" below. (Who - what - when - where - why - how?)
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Enter description here
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Add media
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Lessons learned?
Injury
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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, leave the space blank or type "N/A".
General Incident Information
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Date & Time of Incident
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Time Work Started
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Specific Incident Location
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Witnesses?
Injury Information
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Injury Type
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Name of Employee
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Phone Number
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Occupation
- Bricklayer
- Glazier
- Ironworker
- Laborer
- Operator
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Age
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Years Employed?
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EMS Notified?
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Has the injured employee been taken to a clinic/hospital?
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Clinic Name & Location
Incident Description
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Describe clearly what took place. Include materials, equipment, and environmental conditions involved in the incident. Provide information that led up to the incident. Include photos by selecting "Add Media" below. (Who - what - when - where - why - how?)
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Enter description here
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Add media
Property Damage
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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, leave the space blank or type "N/A".
General Incident Information
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Date & Time of Incident
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Time Work Started
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Specific Incident Location
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Witnesses?
Property Damage
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Nature of Damage
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Equipment/Machinery Involved
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Make/Model/Equipment Number
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List person(s) involved
Incident Description
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Describe clearly what took place. Include materials, equipment, and environmental conditions involved in the incident. Provide information that led up to the incident. Include photos by selecting "Add Media" below. (Who - what - when - where - why - how?)
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Enter description here
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Add media
