Title Page

  • Office Location

  • Conducted on

  • Prepared by

  • Location
  • Required to be completed when there is workplace incident (auto or worker's compensation).
    Completed forms should be email to claims@drsinstall.com within 24 hours of the incident.

Incident Type

  • What type of incident was this? (Auto, Worker's Comp.)

  • Employee's Name

  • Date and time of the incident

  • Location of the incident

  • Were you contacted and notified on the day of the incident?

  • Date and time notified

  • Why wasn't the injury reported the day of the incident?

  • Did you travel to the incident location?

  • How many miles did you travel?

  • What time did you arrive?

  • Why didn't you travel to the incident?

Work Related Injury

  • What part of the body was injured?

  • What was the nature of the injury? (laceration, puncture, break, strain, bite, rash, etc.)

  • Why did the employee do what they did?

  • Was medical treatment requested?

  • Were they taken or directed to go?

  • Where was the technician taken for medical treatment?

  • Complete a DRS Declination of Treatment form on iAuditor and email to claims@drsinstall.com.

  • Was equipment, tools, or PPE involved in this injury?

  • What equipment or tools were used?

  • Were they used correctly?

  • Was regular maintenance of the equipment carried out?

Auto Incident

  • Was the employee injured in the auto incident?

  • Fill out the section in the Work Related Injury Category.

  • Was anyone else injured?

  • List the names of the injured, their injury, and contact information

  • How were they transported and where?

Incident Information

  • Describe in full how the incident happened.

  • What other factors contributed to this incident (weather, lighting, accessibility, condition of property, temperature, etc.)?

  • Were Safety policies and procedures followed?

  • Explain what unsafe acts or conditions were not followed.

  • Were the safety rules communicated to and understood by the employee?

  • Had this hazard been previously identified?

  • What is your recommendation for preventative action to take in the future to prevent repeating this incident?

  • Was disciplinary action taken, if needed?

  • What disciplinary action was taken?

  • Any observations, comments, or concerns about this incident after you completed your investigation?

  • Supervisor's Signature

  • This completed form should be emailed to claims@drsinstall.com within 24 hours of the incident.

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.