CX Paving Solutions - Accident Damage Report Form

• Date

  Date

• Time

• Site Location

• Exact Location

• Report completed by

1. Accident

• Injured Persons Name

• Injured Persons Address

• Injured Persons Date of Birth

• Status of Injured Person

  Employee

  Contractor

  Customer

  Haulier

  Member of Public

• Description of Injuries

• Treatment Required

  Yes

  No

  N/A

• If Yes, provide details of treatment

• Follow up Action Taken

  Referred to Doctor

  Sent to Hospital

  Minor First aid

  Taken to hospital by any means

  Other

2. Dangerous Occurrence

• Please provide details of the Dangerous Occurrence

3. Incident / Damage Report

• Type of incident / Damage?

  Underground Sevice

  Overhead Service

  Vehicle

  Property

  Other

• Type of Service Damaged (if applicable)?

  Gas

  Electric

  Water

  Phone

  Cable

• Details of Incident / Damage

• Photos of Incident / Damage

  Media

• What Caused the Incident / Damage?

• CEMEX Responsibility

  Yes

  No

  N/A

• Estimated Cost of Damage?

• Owner of Service (If applicable)?

Signature

• Person completing Form

  Sign