Evers and Sons Incident Investigation Report

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Investigation Status

  Pending

  Completed

• Prepared by

• Investigation Team

Incident Occurance

• Date And Time The Incident Occurred/Discovered:

  Date

• Date And Time The Incident Was Reported:

  Date

• Customer and Project:

• Incident Location:
  Address

Incident Classification

• Information Report / Non-Work Related

• Near Miss

• Spill / Release

• Is the spill reportable? (More than 5bbl of liquid.)

  Non-Reportable

  Reportable

• Estimate Amount Spilled:

• Property Damage

• Minor = Valued less than $5000.00 / Major = Valued more than $5000.00

  Estimate Pending

  Minor

  Major

• Injury

• Injury Classification:

  Select Minor First Aid First Aid Recordable Restricted Duty Lost Time

  • Minor First Aid
  • First Aid
  • Recordable
  • Restricted Duty
  • Lost Time

Employee Information

• Employee Information:

Employee

• Employee's Full Name

• Employee Trade

• Employee ID Number:

• Employee Gender:

  Male

  Female

• Employee's Date Of Birth:

  Date

• Short Service Employee?

  Yes

  No

• Employee's Phone Number:

• Injury / Illness

  Yes

  No

• Describe the location and nature of the injury:

• Was Axiom Contacted?

  Yes

  No

  N/A

• Describe Treatment:

• Was the Employee taken to a Medical Clinic or Hospital?

  Yes

  No

• Name, Location, and phone number of the Clinic.

• Name of the attending Physician.

• Was prescription medication administered or given?

  Yes

  No

  N/A

• Was the employee released to full duty? (If not, list restrictions)

  Yes

  No

  N/A

Property Damage

• Property Damage

Property

• Property Owner's Information:

• Description of property and damage:

• Vehicle Damage

Vehicle

• Vehicle Owner:

  Select Main Office Toyah

  • Main Office
  • Toyah

• Vehicle Owner's Information:

• Vehicle Description (Y/M/M):

• Describe Vehicle Damage:

• Equipment Damage

Equipment

• Manufacturer:

• Equipment Type:

• Equipment Number:

• Describe Damage:

Utility Damage

• Utility Damage

Utility

• Type of Utility:

  Select Electrical Line Telephone Line Television Cable Fiber Optic Line Pipeline (Gas/Oil) Water Line Sewer Line Other

  • Electrical Line
  • Telephone Line
  • Television Cable
  • Fiber Optic Line
  • Pipeline (Gas/Oil)
  • Water Line
  • Sewer Line
  • Other

• Is the line regulated by the DOT?

  Yes

  No

  N/A

• Depth of damaged utility line:

• Utility Owner:

• Cable / Line Size:

• Were Locates Requested?

  Yes

  No

  N/A

• Was the "One Call" Current?

  Yes

  No

  N/A

• One-Call Ticket Number:

• Texas811

  Lonestar811

• One-Call Emergency Dig Up Ticket Number:

• Check Damage Prevention Service:

  Texas811

  Lonestar811

• Was The Utility Located?

  Yes

  No

  N/A

• Were The Locates Correct?

  Yes

  No

  N/A

• Was a "Blind Sweep" conducted?

  Yes

  No

  N/A

• We're all customer required permits completed?

  Yes

  No

  N/A

Description Of Events

• Brief Description Of Incident:

• Additional Investigation Information:

• Causes Or Factors:

• Preventative Measures:

  Yes

  No

  N/A

• Preventative Measures:

• Attach Photos:

  Media

• Photo Notes:

• Diagrams:

  Drawing

Close Out

• Auditor Name:

  Sign

• Auditor Signature

  Sign