Incident, Accident/Collision, Injury, and Near Miss Report

• Conducted on

  Date

• Prepared by

• Location
  Address

Incident, Accident/collision, Injury, and Near Miss Report

• Type of Report

  Select Incident Accident/collision Near Miss Injury Fatality

  • Incident
  • Accident/collision
  • Near Miss
  • Injury
  • Fatality

• Injured name (First and Last)

• Sex?

  Male

  Female

• Social Security Number

• Phone Number

• Date of Birth

• Language

  English

  Spanish

• Race

  Asian

  Black

  White

• Ethnicity

  Select African American Asian Caucasian Hispanic Native American Native Hawaiian or Pacific Islander

  • African American
  • Asian
  • Caucasian
  • Hispanic
  • Native American
  • Native Hawaiian or Pacific Islander

• Mailing Address

• County

• Marital Status

  Married

  Single

  Divorced

• Number of Dependents

• Spouses Name

• Date of Hire

• State hired or recruited in

• Date current position began

• Date occupation began

• Occupation of injured worker

• Rate of pay

• Amount of hours normally worked per week

• Amount of days normally worked per week

• Last paycheck wages

• Last paycheck was how many hours or days

• Is employee an owner/partner or corporate officer?

  YES

  NO

• Date/time of Injury

  Date

• Date loss time began

  Date

• Nature of injury (cut, broken bone, strain, etc)

• Part of body injured or exposed

• Part of body left/right

  Left

  Right

• How and why injury occurred

• Was employee doing his/her regular job?

  YES

  NO

• Work site location? (Stairs, dock, etc)

• Name of business where injured

• Address

• County

• Cause of injury (fall, tool, machine, etc)

• Return to work date

• Date of Death

• Supervisors name (first/last)

• Treating Doctor's Name

• Name and address of treating medical facility.

• Was an accident/police report created?

  Yes

  No

  N/A

• Agency name and report number?

• Were any citations given at the scene?

  YES

  NO

• What type of citation?

• Insurance Carrier

• Drivers license number

• Phone Number

• License plate information

• Branch:

  Select Vista Fontana Phoenix Tucson Buda Lancaster Houston Baton Rouge Lake Charles Slidell

  • Vista
  • Fontana
  • Phoenix
  • Tucson
  • Buda
  • Lancaster
  • Houston
  • Baton Rouge
  • Lake Charles
  • Slidell

• Date of report:

  Date

Employee Information:

• Employee Name:

• Ph#:

• Unit#:

• Date and time employee began work:

  Date

• Total hours worked since last day off:

• Date of incident:

  Date

• Details of Incident:

• Location of incident:

• Jobsite Foreman / Supervisior / Officer:

• Name of Witnesses include phone number (Contact information)

• In your opinion, who was at fault?

  Western Employee

  Other Party

• Explain how to avoid a similar incident: (Use detail and a real solution/suggestion)

• Date of Hire:

  Date

• Hours worked previous day:

• Hours worked during current pay period:

• Is there cause for reasonable suspicion?

  YES

  NO

• When was the employee's last evaluation?

  Date

• Describe past performance:

  Excellent

  Very Good

  Fair

  Poor

  Unacceptable

• Was the employee wearing proper PPE?

  YES

  NO

• Was the incident avoidable?

  YES

  NO

• Is more training needed?

  YES

  NO

• If so, what type?

• If the employee was at fault.

  Written warning

  Terminated

  N/A not at fault

• Office Notes:

• Supervisor's signature/Person creating report:

  Sign