Accident / Incidnet Report

Information

  • Report Prepared By

  • Select date

  • Phone Number

  • Contacted Safety Officer

  • Name of Safety Officer

#1 Project Information

  • Jobsite Name

  • Add location
  • Project Manager

  • Superintendent

  • Foreman

  • Safety Coordinator

#2 Employee / Incident Information

  • Employee Name

  • SSN#

  • DOB

  • Address

  • Home Phone Number

  • Date of Hire

  • 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

  • Day Of Week

  • Date Reported to Dome

  • Reported to Whom at Dome

  • Type of Injury

  • Part of Body Injured

  • Was First Aid Given

  • By Whom

  • Was Employee Taken to a Medical Facility Offsite

  • Select date

  • Treating Facility

  • Facility Phone No.

  • Transported by

  • Name of Driver

  • Employee Returned to

  • Estimated Return Date

  • Employee's Supervisor

  • Working on a Crew

  • Crew Size

#4 Incident Designation (checked by safety professional only)

  • Name

  • Designation

#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

  • Add media

  • Add media

  • Add media

  • Add 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

  • Was employee instructed in the safe use of this equipment

  • Describe in detail & include copies of equipment certifications

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

  • Was any recent maintenance/service performed on this equipment

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

  • Were standard work procedures followed

  • 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

  • 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

  • Name of leader

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

#8 Reviewed and acknowledged

  • Safety Coordinator

  • Select date

  • Foreman

  • Select date

  • Superintendent

  • Select date

  • Project Manager

  • Select date

#9 Routing - Please Email to

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

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

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