Chris-Tel- Special Projects- Report of Incident

• Conducted on

  Date

• Prepared by

• Location
  Address

• Project Name

• Location/Station of Incident

• Report Date

  Date

• Date/Time of Incident

  Date

• Description of Incident

• Organizations Involved in Incident

• Did incident impact the job?

  Yes

  No

  N/A

• Describe Impact to the Job

• Was weather a contributing factor in the incident?

  Yes

  No

  N/A

• Describe weather conditions and how it impacted the job

Injuries

• Was anyone injured?

  Yes

  No

  N/A

• Name (1)

• Company (if applicable)

• Describe injury and body part, if applicable

• Contact info

• Name (2)

• Company (if applicable)

• Describe injury and body part, if applicable

• Contact Info

• Name (3)

• Company (if applicable)

• Describe injury and body part, if applicable

• Contact Info

• Was First Aid provided?

  Yes

  No

  N/A

• If yes, describe what first aid was provided

• Was additional medical treatment required?

  Yes

  No

  N/A

• If Yes, describe additional medical treatment details

  Yes

  No

  N/A

• Was EMS required?

  Yes

  No

  N/A

• Were injuries treated onsite by EMS?

  Yes

  No

  N/A

• Was Injured transported to a medical facility?

  Yes

  No

  N/A

• Was there Property Damage? If yes, provide details and also fill out a CLAIMS REPORT

  Yes

  No

  N/A

• Description of Property Damage

• Were Police notified of incident?

  Yes

  No

  N/A

• Provide Officer Info

• Was a copy of the police report received? Case number?

• Yes

  No

  N/A

• Witness Name (1)

• Contact Number/ email

• Witness Name (2)

• Contact Number/ email

• Witness Name (3)

• Contact Number/ email

• Add signature

  Sign