Dome Construction Accident / Incident Report

Information

• Report Prepared By

• Select date

  Date

• Phone Number

• Contacted Safety Officer

• Name of Safety Officer

#1 Project Information

• Jobsite Name

• Add location
  Address

• Project Manager

• Superintendent

• Foreman

• Safety Coordinator

#2 Employee / Incident Information

• Employee Name

• SSN#

• DOB

  Date

• Address

• Home Phone Number

• Date of Hire

  Date

• Job Title

• End Time

• Exact Location Of Incident (Bldg/Leve/Area)

• General Task At Time Of Incident (i.e. Moving Strut)

• Specific Activity At Time Of Incident (i.e. Bending Over To P/U Strut)

#3 Injury / Illness Information

• Date and Time of Incident

  Date

• Day Of Week

  Select Monday Tuesday Wednesday Thursday Friday Saturday Sunday

  • Monday
  • Tuesday
  • Wednesday
  • Thursday
  • Friday
  • Saturday
  • Sunday

• Date Reported to Dome

  Date

• Reported to Whom at Dome

• Type of Injury

• Part of Body Injured

• Was First Aid Given

  Yes

  No

• By Whom

• Was Employee Taken to a Medical Facility Offsite

  Yes

  No

• Select date

  Date

• Treating Facility

• Facility Phone No.

• Transported by

  Ambulance

  Company Vehicle

  Private Vehicle

• Name of Driver

• Employee Returned to

  Regular Work

  Modified Work

  Has Not Returned

• Estimated Return Date

  Date

• Employee's Supervisor

• Working on a Crew

  Yes

  No

• Crew Size

#4 Incident Designation (checked by safety professional only)

• Name

• Designation

  Select First Aid Incident Recordable Incident Lost Time Incident Incident Only Not Determined at This Time

  • First Aid Incident
  • Recordable Incident
  • Lost Time Incident
  • Incident Only
  • Not Determined at This Time

#5 Description of the Incident (not to be completed by the injured worker)

• Describe in detail the circumstances of the incident (attach diagrams, drawings and/or photos of accident scene). Give chronological sequence of events. If materials and/or equipment were involved, start before the materials/equipment were brought to the incident scene describing who, what, where, when, how:

• Attach Photo

  Off

  On

• Add media

  Media

• Add media

  Media

• Add media

  Media

• Add media

  Media

• The following is a summary of events

#6 Additional Information

• Name of witnesses and others working with injured worker (include statements with report)

• Objects, substance, equip. involved in incident (desc/model/serial #)

• List PPE worn at time of incident

• Safety equipment & training required for job

• Does employee normally operate this equipment

  Yes

  No

• Was employee instructed in the safe use of this equipment

  Yes

  No

• Describe in detail & include copies of equipment certifications

• Was any defect with the equipment noted or reported prior to accident/incident

  Yes

  No

• Was any recent maintenance/service performed on this equipment

  Yes

  No

• When/What? Describe in detail and include copies of invoices/work orders

• Were standard work procedures followed

  Yes

  No

• Why not - Describe in detail, include additional sheets if necessary and include a copy of the standard site procedures

• Was a safety rule or specific instruction violated

  Yes

  No

• What - Describe in detail, include additional sheets if necessary and include a copy of the rule/regulation

• When/How was this rule, regulation or specific instruction communicated to the injured worker(s)

#7 Corrective Action Plan

• Corrective action(s) and completion date(s)

• Date of next scheduled toolbox safety meeting

  Date

• Name of leader

• Has the meeting leader been provided with this information for discussion

  Yes

  No

#8 Reviewed and acknowledged

• Safety Coordinator

  Sign

• Select date

  Date

• Foreman

  Sign

• Select date

  Date

• Superintendent

  Sign

• Select date

  Date

• Project Manager

  Sign

• Select date

  Date

#9 Routing - Please Email to

• Safety Officer: Frank Zamora, Email: Frank@domeconst.com

• Human Resource Director: Virginia Preciado, Email: Virginia@domeconst.com