Hy-Vee Construction Incident Report

• Job Site

• Job Number

• Job Site Address
  Address

• Date

  Date

Injured Persons Information

• Type of Employee:

  Hy-Vee Construction Employee

  Subcontractor Employee

• Name:

• Address:

• Phone Number:

• Date of Birth:

• Social Security Number:

• Marital Status:

  Married

  Separated

  Unmarried

• Date Hired:

• How Long In Occupation:

• Job Title:

• Injured Persons Signature:

  Sign

Incident Information

• Type of Incident:

  Injury

  Illness

• Date & Time of Incident:

  Date

• Incident Reported To:

• Date Incident Reported:

  Date

• Time workday began:

  Date

• Phase of Employee's Workday During Incident:

  During Rest or Meal Period

  Entering or Leaving Facility

  Working Overtime

  Performing Work Duties

  Other

• Drug Testing:

  Yes

  No

• If no, explain why:

• Injury/Illness type (Be specific, example laceration, sprain, bruise):

• Explain injury (Indicate body part that hurts -right/left side, etc.):

• Describe how incident occurred:

• Attach photos (If available):

  Media

• Task and activity at time of incident:

• Was the injured person wearing PPE at the time of the incident?

  Yes

  No

• If yes, list items. If no, explain why:

• Was the injured person working:

  Alone

  With Crew

  Other

• Was any other person involved?

  Yes

  No

• If yes, explain:

• Was equipment a contributing factor?

  Yes

  No

• If yes, explain:

• What factors appear to have caused this incident?

• List name(s) of witness(es):

Witness Report

• Witness Name:

• Witness Phone Number:

• Where on the job site did the incident occur?

• Where on the job site were you located?

• What visible injuries did you note?

• What did the employee say?

• Was the injured person following safety policies?

  Yes

  No

• If no, explain:

• What actions could the injured person have taken to prevent this incident?

• Witness Signature:

  Sign

Supervisors Report

• Supervisor Name:

• Supervisor Phone Number:

• Date and time Supervisor was notified:

  Date

• Was the employee following safety policies?

  Yes

  No

• If no, explain:

• What actions could the employee have taken to prevent this incident?

• Do you have knowledge of any medical conditions pertaining to this employee?

• Was the location or position of equipment/material or injured person a contributing factor?

  Yes

  No

• If yes, explain:

• Was the job procedures used a contributing factor?

  Yes

  No

• If yes, explain:

• Was lack of PPE or emergency equipment a contributing factor?

  Yes

  No

• If yes, explain:

• What corrective measures will be implemented and when? Name those responsible:

• Supervisor Signature:

  Sign