INCIDENT / INJURY REPORT FORM

• Company Location

  Select

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• Type of Incident

• Conducted on

  Date

• Person Conducting Report

• Location of Incident
  Address

• Date / Time of Incident / Injury

  Date

• Truck #

• Driver Name

• Driver Phone Number

• Hopper / Helper Name If Any

• Supervisor Name

• Was medical treatment given ?

  Yes

  No

  N/A

• If medical treatment was refused, please have employee sign here.

  Sign

• NOTE - An employee may refuse medical treatment, but cannot refuse the post incident drug and alcohol screen.

• ALL work-related injuries and vehicle crashes involving a 3rd party must have an immediate post injury drug and alcohol screening. Property damage incidents will be decided on a case-by-case scenario, if the employee involved will receive a post incident screen. Please call Danielle Guidry or Jeff Lirette for determination for property damages.

• List names and contact information for all third-party persons involved.

• Police Report

  Yes

  No

  N/A

• Police Report - Agency

• Police Report - Officers Name

• Police Report - Case #

• Full description of incident / injury. Please be as detailed as possible.

• Photos of the incident / injury are required. Please upload photos below.

• Upload Photo

  Media

• Supervisor Signature

  Sign

• Employee Signature

  Sign

SAFETY DEPARTMENT NOTES (This section is ONLY for the Safety Department)

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