Contractor Preliminary Incident Report

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

Employee Information

• Name of Contractor

• Contractor Foreman at Scene

Location and Time Information

• Address of Incident

• Location # of Incident

• Date and Time of Incident

  Date

• Date and Time Incident Reported to UPC Contact

  Date

Incident Information

• Type of Incident

  Select Uncontrolled Release of Energy Equipment Damage Personal Injury Vehicle Collision Property Damage Unexpected Event Close Call Equipment Failure Damaged Other Utility

  • Uncontrolled Release of Energy
  • Equipment Damage
  • Personal Injury
  • Vehicle Collision
  • Property Damage
  • Unexpected Event
  • Close Call
  • Equipment Failure
  • Damaged Other Utility

• Any Damage to Equipment?

  Yes

  No

  N/A

• Describe Equipment Damage

• Picture of Damage

  Media

• Weather Conditions

  Select Sunny Overcast Dark Raining Breezy Fog Hot Cold Moderate Snow/Sleet High Winds Frost Wet

  • Sunny
  • Overcast
  • Dark
  • Raining
  • Breezy
  • Fog
  • Hot
  • Cold
  • Moderate
  • Snow/Sleet
  • High Winds
  • Frost
  • Wet

• Equipment, Tool, or Condition Causing Incident

• Employees Statement of Events

• Investigator’s Observations

• Picture of Incident

  Media

Damaged Utility Information

• Was locate request made to NC811

  Yes

  No

  N/A

• Were utilities located at the time of the damage

  Yes

  No

  N/A

• Locate number

• Locate start date

• Locate end date

• Were locates accurate

  Yes

  No

  N/A

• Locates were off by

• Picture of work order locates

  Media

• Other Company(s) or People Involved?

  Yes

  No

  N/A

• Names and Phone Numbers

• Additional Information

• Investigation Team

Medical Information

• If Personal Injury, What Body Parts(s) Incurred Injury(s)?

• Picture of Injury

  Media

• Did Injury Require More Than Basic First Aid?

  Yes

  No

  N/A

Signatures

• EHS Director Signature

  Sign