Incident Notes LEE

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

GENERAL INFORMATION:

• Select date

  Date

• Job name:

• Job site address:
  Address

• Number of employees on site:

• Job start time:

• Job quit time:

• Number of days the job is working each week:

• Pictures / video of the entire work area:

• Copies of PTA / STAC card:

• Copies of toolbox talks:

• Request any sign in / badge records:

• Notify Project Manager/ Shop Superintendent:

• Area is safe to enter:

• Was there an injury caused by the incident?

  Yes

  No

  N/A

• Is the area safe to enter?

  Yes

  No

  N/A

• Explain why?

• Was the person treated with first-aid on site?

  Yes

  No

  N/A

• Who administered first-aid?

• Describe treatment:

• Was the person taken off site for further medical treatment / evaluation?

  Yes

  No

  N/A

• Was the person taken off site by emergency medical services?

  Yes

  No

  N/A

• Enter any information about the emergency medical service personnel (names, squad #, city, etc.):

• Who took the person for further medical treatment / evaluation?

• Where was the person taken for further medical treatment / evaluation?

• Did the incident cause any vehicle damage?

  Yes

  No

  N/A

• Is the vehicle owned by Lake Erie Electric?

  Yes

  No

  N/A

• What is the id / license plate # for the vehicle?

• Take pictures of the incident:

  Media

• What is the id / license plate # for the vehicle?

• Take pictures of the incident:

  Media

• Get other persons insurance information:

• Request a copy of any reports being made:

• Describe the incident:

• How did the incident occur?

• Who was involved in the incident?

• Did the incident cause any property damage?

  Yes

  No

  N/A

• Take pictures of the damage:

  Media

• Describe the damage:

• How did the incident occur?

• Who was involved in the incident?

• Project Manager:

• Foreman:

EMPLOYEE INFORMATION:

• Employee name:

• Number of years working in the trade:

• Hire date with Lake Erie Electric:

• When did the incident occur?

• What PPE was being used at the time of the incident?

• Description of work being performed?

• Are you an apprentice?

  Yes

  No

  N/A

• Employee:

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WITNESS TO THE INCIDENT:

• Name:

• Employer:

• Position / Title:

• Did you see the incident happen?

  Yes

  No

  N/A

• Where where you when the incident occurred?

• What time did the incident happen?

• Detailed description of the incident:

• What PPE did he/she have on at the time of the incident?

• Describe the incident as it was described to you:

• Who reported the incident to you?

• Did he/she appear to injured?

  Yes

  No

  N/A

• What injuries were apparent?

• Did you speak to the person?

  Yes

  No

  N/A

• What did he/she say to you?

• Did you offer assistance?

  Yes

  No

  N/A

• What did he/she say?

• If any, what assistance was given?

• Witness to incident:

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SUPERVISOR STATEMENT:

• Name:

• Did you see the incident happen?

  Yes

  No

  N/A

• Where were you when the incident happened?

• What time did the incident happen?

• Describe the incident:

• What PPE did he/she have on at the time of the incident?

• Did you offer assistance?

  Yes

  No

  N/A

• What did he/she say?

• If any, what assistance was given?

• Describe the incident as it was reported to you:

• Who reported the incident to you?

• What time was the incident reported to you?

• Did he/she appear to be, or was reported to be, injured?

  Yes

  No

  N/A

• What injuries were noted or reported?

• Was the injury addressed with first-aid on site?<br>

  Yes

  No

  N/A

• Describe treatment:

• Did he/she have to be taken off site for further medical treatment, or evaluation?

  Yes

  No

  N/A

• Where was he/she taken for medical treatment/evaluation?

• Supervisor:

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