Title Page

  • Date and Time of Incident:

  • Employee Name:

  • Incident Type:

  • Collision Crash Type:

  • Non-Collision Crash Type:

  • Report Number:

  • Report Prepared by:

Incident Details - EAP

General Information

  • Employee Id:

  • Employee name:

  • Date of birth:

  • Address:

  • Phone number:

Employment Information

  • Date of hire:

  • Employee title:

  • Division:

  • Operation:

  • Immediate supervisor:

  • Supervisor:

  • Parking location:

  • Truck:

  • Trailer:

  • Operation:

  • Transfer Station:

  • Location:

  • Immediate Supervisor

Incident Information

  • Incident type:

  • Incident location:

  • Highway/City:

  • Facility:

  • Facility:

  • Site Supervisor:

  • Specific location on company premises where incident occurred:

  • Landfill:

  • Landfill:

  • Site Supervisor:

  • Specific location on landfill where incident occurred:

  • Transfer Station:

  • Transfer Station:

  • Site Supervisor:

  • Specific location on transfer station where incident occurred:

  • What was the employee doing at the time of the incident

  • Other:

  • First Harmful Event:

  • How did the vehicle collision occur?

  • Movement preceding collision:

  • Number of vehicles involved:

  • Weather Conditions:

  • Surface Conditions:

  • Other:

Collision Crash - Injuries

  • Did the employee involved sustain any injuries as a result of this incident?

  • Injury or Illness:

  • Other:

  • Bodily location of injury:

  • Injured Body Parts:

  • Right/Left/Both:

  • Multiple Injured Body Parts:

  • Did the employee involved receive medical attention?

  • Medical care provider:

  • Clinic:

  • Clinic:

  • Was the employee involved transported to a hospital?

  • Hospital:

  • Was the employee involved hospitalized overnight as an in-patient?

  • Medical Treatment:

Collision Crash - Regulatory

  • Did law enforcement arrive on scene?

  • Agency:

  • Report #:

  • Was the employee involved sent for Post-Accident DOT Drug & Alcohol Testing?

  • Post-Accident Testing Location:

  • Clinic:

  • If No, Explain:

  • Object Description:

  • How did the vehicle collision occur?

  • Movement preceding collision:

  • Weather Conditions:

  • Surface Conditions:

Collision Crash - Injuries

  • Did the employee involved sustain any injuries as a result of this incident?

  • Injury or Illness:

  • Other:

  • Bodily location of injury:

  • Injured Body Parts:

  • Right/Left/Both:

  • Multiple Injured Body Parts:

  • Did the employee involved receive medical attention?

  • Medical care provider:

  • Clinic:

  • Clinic:

  • Was the employee involved transported to a hospital?

  • Hospital:

  • Was the employee involved hospitalized overnight as an in-patient?

  • Medical Treatment:

Collision Crash - Regulatory

  • Did law enforcement arrive on scene?

  • Agency:

  • Report #:

  • Was the driver of the company vehicle sent for Post-Accident DOT Drug & Alcohol Testing?

  • Post-Accident Testing Location:

  • Clinic:

  • If No, Explain:

  • How did the vehicle collision occur?

  • Movement preceding collision:

  • Weather Conditions:

  • Surface Conditions:

Collision Crash - Injuries

  • Did the employee involved sustain any injuries as a result of this incident?

  • Injury or Illness:

  • Other:

  • Bodily location of injury:

  • Injured Body Parts:

  • Right/Left/Both:

  • Multiple Injured Body Parts:

  • Did the employee involved receive medical attention?

  • Medical care provider:

  • Clinic:

  • Clinic:

  • Was the employee involved transported to a hospital?

  • Hospital:

  • Was the employee involved hospitalized overnight as an in-patient?

  • Medical Treatment:

Collision Crash - Regulatory

  • Did law enforcement arrive on scene?

  • Agency:

  • Report #:

  • Was the driver of the company vehicle sent for Post-Accident DOT Drug & Alcohol Testing?

  • Post-Accident Testing Location:

  • Clinic:

  • If No, Explain:

  • What was the employee doing at the time of the incident

  • Other:

  • Incident location:

  • Highway:

  • City/State:

  • Facility:

  • Facility:

  • Site Supervisor:

  • Specific location on company premises where incident occurred:

  • Landfill:

  • Landfill:

  • Site Supervisor:

  • Specific location on landfill where incident occurred:

  • Transfer Station:

  • Transfer Station - Name/Address:

  • Site Supervisor:

  • Specific location on transfer station where incident occurred:

  • Non-collision crash type:

  • Other:

  • How did the non-collision crash occur?

  • Movement preceding non-collision crash:

  • Weather conditions:

  • Other:

  • Surface conditions:

  • Other:

Non-Collision Crash - Injuries

  • Did the employee involved sustain any injuries as a result of this incident?

  • Injury or Illness:

  • Other:

  • Bodily location of injury:

  • Injured Body Parts:

  • Right/Left/Both:

  • Multiple Injured Body Parts:

  • Did the employee involved receive medical attention?

  • Medical care provider:

  • Clinic:

  • Clinic:

  • Was the employee involved transported to a hospital?

  • Hospital:

  • Was the employee involved hospitalized overnight as an in-patient?

  • Medical Treatment:

Non-Collision Crash - Regulatory

  • Did law enforcement arrive on scene?

  • Agency:

  • Report #:

  • Was the employee involved sent for post-accident DOT drug & alcohol testing?

  • Post-accident testing location:

  • Clinic:

  • If No, Explain:

  • What was the employee doing at the time of the incident

  • Other:

  • Incident location:

  • Highway:

  • City/State:

  • Facility:

  • Landfill:

  • Landfill - Name/Address:

  • Transfer Station:

  • How did the incident occur?

  • Weather Conditions:

  • Surface Conditions:

  • Other:

Equipment Damage - Injuries

  • Did the employee involved sustain any injuries as a result of this incident?

  • Injury or Illness:

  • Other:

  • Bodily location of injury:

  • Injured Body Parts:

  • Right/Left/Both:

  • Multiple Injured Body Parts:

  • Did the employee involved receive medical attention?

  • Medical care provider:

  • Clinic:

  • Clinic:

  • Was the employee involved transported to a hospital?

  • Hospital:

  • Was the employee involved hospitalized overnight as an in-patient?

  • Medical Treatment:

Equipment Damage - Regulatory

  • Did law enforcement arrive on scene?

  • Agency:

  • Report #:

  • Was the employee involved sent for post-accident DOT drug & alcohol testing?

  • Post-accident testing location:

  • Clinic:

  • If No, Explain:

  • What was the employee doing at the time of the incident

  • Incident location:

  • Highway:

  • City/State:

  • Facility:

  • Site Supervisor:

  • Specific location on company premises where incident occurred:

  • Landfill:

  • Landfill:

  • Specific location on landfill where incident occurred?

  • Transfer Station:

  • Transfer Station:

  • Specific location on transfer station where incident occurred:

  • How did the incident occur?

  • What object or substance harmed the employee?

  • Injury or Illness Type:

  • Other:

  • Bodily location of injury:

  • Injured Body Parts:

  • Right/Left/Both:

  • Multiple Injured Body Parts:

  • Did the employee involved receive medical attention?

  • Type of Medical Treatment:

  • Clinic:

  • Clinic:

  • Address:

  • City/State:

  • Zip Code:

  • Did the driver of the company vehicle receive medical treatment in an emergency room?

  • Hospital:

  • Address:

  • City/State:

  • Zip Code:

  • Was the driver of the company vehicle hospitalized overnight as an in-patient?

  • Medical Treatment:

  • Division

  • Operation

  • Immediate supervisor

  • Parking location

  • Operation:

  • Transfer station:

  • Location:

  • Immediate supervisor

Incident Information

  • Incident type:

  • What was the employee doing at the time of the incident

  • Incident location:

  • Highway/City:

  • Facility:

  • Facility:

  • Site Supervisor:

  • Specific location on company premises where incident occurred:

  • Landfill:

  • Landfill:

  • Site Supervisor:

  • Specific location on landfill where incident occurred:

  • Transfer Station:

  • Transfer Station:

  • Site Supervisor:

  • Specific location on transfer station where incident occurred:

  • Street/City:

  • County Road/City:

  • Other:

  • First harmful event:

  • How did the vehicle collision occur?

  • Movement preceding collision:

  • Number of vehicles involved:

  • Weather conditions:

  • Surface conditions:

  • Other:

Collision Crash - Injuries

  • Did the employee involved sustain any injuries as a result of this incident?

  • Injury or Illness:

  • Other:

  • Bodily location of injury:

  • Injured Body Parts:

  • Right/Left/Both:

  • Multiple Injured Body Parts:

  • Did the employee involved receive medical attention?

  • Medical care provider:

  • Clinic:

  • Clinic:

  • Was the employee involved transported to a hospital?

  • Hospital:

  • Was the employee involved hospitalized overnight as an in-patient?

  • Medical Treatment:

Collision Crash - Regulatory

  • Did law enforcement arrive on scene?

  • Agency:

  • Report #:

  • Was the employee involved sent for post-accident DOT drug & alcohol testing?

  • Post-Accident Testing Location:

  • Clinic:

  • If No, Explain:

  • Object Description:

  • How did the vehicle collision occur?

  • Movement preceding collision:

  • Weather Conditions:

  • Surface Conditions:

Collision Crash - Injuries

  • Did the employee involved sustain any injuries as a result of this incident?

  • Injury or Illness:

  • Other:

  • Bodily location of injury:

  • Injured Body Parts:

  • Right/Left/Both:

  • Multiple Injured Body Parts:

  • Did the employee involved receive medical attention?

  • Medical care provider:

  • Clinic:

  • Clinic:

  • Was the employee involved transported to a hospital?

  • Hospital:

  • Was the employee involved hospitalized overnight as an in-patient?

  • Medical Treatment:

Collision Crash - Regulatory

  • Did law enforcement arrive on scene?

  • Agency:

  • Report #:

  • Was the employee involved sent for Post-Accident DOT Drug & Alcohol Testing?

  • Post-Accident Testing Location:

  • Clinic:

  • If No, Explain:

  • How did the vehicle collision occur?

  • Movement preceding collision:

  • Weather Conditions:

  • Surface Conditions:

Collision Crash - Injuries

  • Did the employee involved sustain any injuries as a result of this incident?

  • Injury or Illness:

  • Other:

  • Bodily location of injury:

  • Injured Body Parts:

  • Right/Left/Both:

  • Multiple Injured Body Parts:

  • Did the employee involved receive medical attention?

  • Medical care provider:

  • Clinic:

  • Clinic:

  • Was the employee involved transported to a hospital?

  • Hospital:

  • Was the employee involved hospitalized overnight as an in-patient?

  • Medical Treatment:

Collision Crash - Regulatory

  • Did law enforcement arrive on scene?

  • Agency:

  • Report #:

  • Was the employee involved sent for post-accident DOT drug & alcohol testing?

  • Post-Accident Testing Location:

  • Clinic:

  • If No, Explain:

  • What was the employee doing at the time of the incident

  • Incident location:

  • Highway/City:

  • Facility:

  • Facility:

  • Site Supervisor:

  • Specific location on company premises where incident occurred:

  • Landfill:

  • Landfill:

  • Site Supervisor:

  • Specific location on landfill where incident occurred:

  • Transfer Station:

  • Transfer Station - Name/Address:

  • Site Supervisor:

  • Specific location on transfer station where incident occurred:

  • Street/City:

  • County Road/City:

  • Other:

  • Non-collision crash type:

  • Other:

  • How did the non-collision crash occur?

  • Movement preceding non-collision crash:

  • Weather conditions:

  • Other:

  • Surface conditions:

  • Other:

Non-Collision Crash - Injuries

  • Did the employee involved sustain any injuries as a result of this incident?

  • Injury or Illness:

  • Other:

  • Bodily location of injury:

  • Injured Body Parts:

  • Right/Left/Both:

  • Multiple Injured Body Parts:

  • Did the employee involved receive medical attention?

  • Medical care provider:

  • Clinic:

  • Clinic:

  • Was the employee involved transported to a hospital?

  • Hospital:

  • Was the employee involved hospitalized overnight as an in-patient?

  • Medical Treatment:

Non-Collision Crash - Regulatory

  • Did law enforcement arrive on scene?

  • Agency:

  • Report #:

  • Was the driver of the company vehicle sent for post-accident DOT drug & alcohol testing?

  • Post-accident testing location:

  • Clinic:

  • If No, Explain:

  • What was the employee doing at the time of the incident

  • Incident location:

  • Highway/City:

  • Facility:

  • Landfill:

  • Landfill - Name/Address:

  • Transfer Station:

  • Street/City:

  • County Road/City:

  • Other:

  • How did the incident occur?

  • Weather Conditions:

  • Surface Conditions:

  • Other:

Equipment Damage - Injuries

  • Did the employee involved sustain any injuries as a result of this incident?

  • Injury or Illness:

  • Other:

  • Bodily location of injury:

  • Injured Body Parts:

  • Right/Left/Both:

  • Multiple Injured Body Parts:

  • Did the employee involved receive medical attention?

  • Medical care provider:

  • Clinic:

  • Clinic:

  • Was the employee involved transported to a hospital?

  • Hospital:

  • Was the employee involved hospitalized overnight as an in-patient?

  • Medical Treatment:

Equipment Damage - Regulatory

  • Did law enforcement arrive on scene?

  • Agency:

  • Report #:

  • Was the employee involved sent for post-accident DOT drug & alcohol testing?

  • Post-accident testing location:

  • Clinic:

  • If No, Explain:

  • What was the employee doing at the time of the incident

  • Incident location:

  • Highway/City:

  • Facility:

  • Site Supervisor:

  • Specific location on company premises where incident occurred:

  • Landfill:

  • Landfill:

  • Specific location on landfill where incident occurred?

  • Transfer Station:

  • Transfer Station:

  • Specific location on transfer station where incident occurred:

  • Street/City:

  • County Road/City:

  • Other:

  • How did the incident occur?

  • What object or substance harmed the employee?

  • Injury or Illness Type:

  • Other:

  • Bodily location of injury:

  • Injured Body Parts:

  • Right/Left/Both:

  • Multiple Injured Body Parts:

  • Did the employee involved receive medical attention?

  • Type of Medical Treatment:

  • Clinic:

  • Clinic:

  • Address:

  • City/State:

  • Zip Code:

  • Did the driver of the company vehicle receive medical treatment in an emergency room?

  • Hospital:

  • Address:

  • City/State:

  • Zip Code:

  • Was the driver of the company vehicle hospitalized overnight as an in-patient?

  • Medical Treatment:

Damages - EAP

  • Did company property sustain any damages as a result of this incident?

  • Company Property Type:

  • Truck:

  • Truck - Damage severity:

  • Trailer:

  • Trailer - Damage severity:

  • Shade the areas that suffered damages:

  • Was the company vehicle towed?

  • By who and where was the vehicle taken?

  • Was any other type of company property involved in this incident?

  • Company Property
  • Company Property Type:

  • Truck:

  • Truck - Damage severity:

  • Trailer:

  • Trailer - Damage severity:

  • Shade the areas that suffered damages:

  • Was the company vehicle towed?

  • By who and where was the vehicle taken?

  • Powered industrial vehicle type:

  • Damage severity:

  • Shade the areas that suffered damages:

  • Make

  • Model

  • Eco Id:

  • Damage severity:

  • Shade the areas that suffered damages:

  • Make

  • Model

  • Eco Id:

  • Damage severity:

  • Shade the areas that suffered damages:

  • Make

  • Model

  • Eco Id:

  • Damage severity:

  • Shade the areas that suffered damages:

  • Make

  • Model

  • Eco Id:

  • Damage severity:

  • Make

  • Model

  • Eco Id:

  • CV:

  • Damage severity:

  • Shade the areas that suffered damages:

  • Was the company vehicle towed?

  • By who and where was the vehicle taken?

  • Was any other type of company property involved in this incident?

  • Company Property
  • Company Property Type:

  • Tractor:

  • Trailer:

  • Damage severity:

  • Shade the areas that suffered damages:

  • Was the company vehicle towed?

  • By who and where was the vehicle taken?

  • Was any other type of company property involved in this incident?

  • Powered industrial vehicle type:

  • Damage severity:

  • Shade the areas that suffered damages:

  • Make

  • Model

  • Eco Id:

  • Damage severity:

  • Shade the areas that suffered damages:

  • Make

  • Model

  • Eco Id:

  • Damage severity:

  • Shade the areas that suffered damages:

  • Make

  • Model

  • Eco Id:

  • Damage severity:

  • Shade the areas that suffered damages:

  • Make

  • Model

  • Eco Id:

  • Damage severity:

  • Make

  • Model

  • Eco Id:

  • Other:

  • Damage severity:

  • Make

  • Model

  • Eco Id:

  • CV:

  • Other:

  • Was any other type of company property involved in this incident?

  • Company Property
  • Company Property Type:

  • Tractor:

  • Trailer:

  • Damage severity:

  • Shade the areas that suffered damages:

  • Was the company vehicle towed?

  • By who and where was the vehicle taken?

  • Was any other type of company property involved in this incident?

  • Powered industrial vehicle type:

  • Damage severity:

  • Shade the areas that suffered damages:

  • Make

  • Model

  • Eco Id:

  • Damage severity:

  • Shade the areas that suffered damages:

  • Make

  • Model

  • Eco Id:

  • Damage severity:

  • Shade the areas that suffered damages:

  • Make

  • Model

  • Eco Id:

  • Damage severity:

  • Shade the areas that suffered damages:

  • Make

  • Model

  • Eco Id:

  • Damage severity:

  • Make

  • Model

  • Eco Id:

  • Other:

  • Damage severity:

  • Make

  • Model

  • Eco Id:

  • CV:

  • Other:

  • Powered industrial vehicle type:

  • Damage severity:

  • Shade the areas that suffered damages:

  • Make

  • Model

  • Eco Id:

  • Damage severity:

  • Shade the areas that suffered damages:

  • Make

  • Model

  • Eco Id:

  • Damage severity:

  • Shade the areas that suffered damages:

  • Make

  • Model

  • Eco Id:

  • Damage severity:

  • Shade the areas that suffered damages:

  • Make

  • Model

  • Eco Id:

  • Damage severity:

  • Make

  • Model

  • Eco Id:

  • CV:

  • Damage severity:

  • Shade the areas that suffered damages:

  • Was the company vehicle towed?

  • By who and where was the vehicle taken?

  • Was any other type of company property involved in this incident?

  • Company Property
  • Company Property Type:

  • Tractor:

  • Trailer:

  • Damage severity:

  • Shade the areas that suffered damages:

  • Was the company vehicle towed?

  • By who and where was the vehicle taken?

  • Was any other type of company property involved in this incident?

  • Powered industrial vehicle type:

  • Damage severity:

  • Shade the areas that suffered damages:

  • Make

  • Model

  • Eco Id:

  • Damage severity:

  • Shade the areas that suffered damages:

  • Make

  • Model

  • Eco Id:

  • Damage severity:

  • Shade the areas that suffered damages:

  • Make

  • Model

  • Eco Id:

  • Damage severity:

  • Shade the areas that suffered damages:

  • Make

  • Model

  • Eco Id:

  • Damage severity:

  • Make

  • Model

  • Eco Id:

  • Other:

  • Damage severity:

  • Make

  • Model

  • Eco Id:

  • CV:

  • Other:

  • Was any other type of company property involved in this incident?

  • Company Property
  • Company Property Type:

  • Tractor:

  • Trailer:

  • Damage severity:

  • Shade the areas that suffered damages:

  • Was the company vehicle towed?

  • By who and where was the vehicle taken?

  • Was any other type of company property involved in this incident?

  • Powered industrial vehicle type:

  • Damage severity:

  • Shade the areas that suffered damages:

  • Make

  • Model

  • Eco Id:

  • Damage severity:

  • Shade the areas that suffered damages:

  • Make

  • Model

  • Eco Id:

  • Damage severity:

  • Shade the areas that suffered damages:

  • Make

  • Model

  • Eco Id:

  • Damage severity:

  • Shade the areas that suffered damages:

  • Make

  • Model

  • Eco Id:

  • Damage severity:

  • Make

  • Model

  • Eco Id:

  • Other:

  • Damage severity:

  • Make

  • Model

  • Eco Id:

  • CV:

  • Other:

Other Party

  • Was there another party involved in this incident besides the Company?

  • Other Party
  • Other Party:

  • Incident with:

Other Party - Injuries

  • Did the other vehicle driver sustain any injuries?

  • Injury severity:

  • Did the other vehicle driver receive medical treatment away from the accident scene?

  • Were there any passengers on the other vehicle?

  • Number of passengers

  • Did any of the passengers on the other vehicle sustain any injuries?

  • Passenger Injuries
  • Age group:

  • Gender:

  • Injury severity:

  • Did the passenger on the other vehicle receive medical treatment away from the accident scene?

Other Party - General Information

  • Driver Name:

  • Address:

  • Phone #:

  • Driver License #:

  • State:

Other Party - Vehicle Information

  • Vehicle Make

  • Other:

  • Vehicle Model:

  • Color:

  • License Plate:

  • State:

Other Party - Insurance Information

  • Insurance Company:

  • Policy #:

  • Policy Expiration Date:

Other Party - Damages

  • Did the other vehicle sustain any damages?

  • Did the vehicle airbags deploy?

  • Damage severity:

  • Shade the areas that suffered damages:

  • Was the other vehicle towed?

  • Was there a car seat in the other vehicle?

  • Other Damages:

  • Shade the areas that suffered damages:

  • Was the Other Vehicle Towed?

  • Was there a car seat in the other vehicle?

  • Did the vehicle airbags deploy?

  • Was there a car seat in the other vehicle?

Other Party - Injuries

  • Were there any persons occupying the parked motor vehicle?

  • Number of occupants:

  • Did any of the occupants on the parked motor vehicle sustain any injuries?

  • Occupant Injuries
  • Age group:

  • Gender:

  • Injury severity:

  • Did the passenger on the other vehicle receive medical treatment away from the accident scene?

Other Party - General Information

  • Driver Name:

  • Address:

  • Phone #:

  • Driver License #:

  • State:

Other Party - Vehicle Information

  • Vehicle Make

  • Other:

  • Vehicle Model:

  • Color:

  • License Plate:

  • State:

Other Party - Insurance Information

  • Insurance Company:

  • Policy #:

  • Policy Expiration Date:

Other Party - Damages

  • Did the other vehicle sustain any damages?

  • Damage severity:

  • Shade the areas that suffered damages:

  • Was the other vehicle towed?

  • Other Damages:

  • Shade the areas that suffered damages:

  • Was the Other Vehicle Towed?

Other Party - Injuries

  • Did the other party sustain any injuries?

  • Injury severity:

  • Did the other party receive medical treatment away from the accident scene?

Other Party - General Information

  • Name:

  • Address:

  • Phone #:

  • Incident with:

Other Company Information

  • Company Name:

  • Contact Person:

  • Phone #:

Other Party - Injuries

  • Did the other vehicle driver sustain any injuries?

  • Injury severity:

  • Did the other vehicle driver receive medical treatment away from the accident scene?

  • Were there any passengers on the other vehicle?

  • Number of passengers

  • Did any of the passengers on the other vehicle sustain any injuries?

  • Passenger Injuries
  • Age group:

  • Gender:

  • Injury severity:

  • Did the passenger on the other vehicle receive medical treatment away from the accident scene?

Other Party - General Information

  • Driver Name:

  • Address:

  • Phone #:

  • Driver License #:

  • State:

Other Party - Vehicle Information

  • Vehicle Make

  • Other:

  • Vehicle Model:

  • Color:

  • License Plate:

  • State:

Other Party - Insurance Information

  • Insurance Company:

  • Policy #:

  • Policy Expiration Date:

Other Party - Damages

  • Did the other vehicle sustain any damages?

  • Damage severity:

  • Shade the areas that suffered damages:

  • Was the other vehicle towed?

  • Other Damages:

  • Shade the areas that suffered damages:

  • Was the Other Vehicle Towed?

Other Company Information

  • Company Name:

  • Contact Person:

  • Phone #:

Other Party - Injuries

  • Were there any persons occupying the parked motor vehicle?

  • Did any of the occupants on the parked motor vehicle sustain any injuries?

  • Occupant Injuries
  • Age group:

  • Gender:

  • Injury severity:

  • Did the passenger on the other vehicle receive medical treatment away from the accident scene?

Other Party - General Information

  • Driver Name:

  • Address:

  • Phone #:

  • Driver License #:

  • State:

Other Party - Vehicle Information

  • Vehicle Make

  • Other:

  • Vehicle Model:

  • Color:

  • License Plate:

  • State:

Other Party - Insurance Information

  • Insurance Company:

  • Policy #:

  • Policy Expiration Date:

Other Party - Damages

  • Did the other vehicle sustain any damages?

  • Damage severity:

  • Shade the areas that suffered damages:

  • Was the other vehicle towed?

  • Other Damages:

  • Shade the areas that suffered damages:

  • Was the Other Vehicle Towed?

Other Company Information

  • Company Name:

  • Contact Person:

  • Phone #:

Other Party - Injuries

  • Was the equipment involved being operated by a person at the time of the incident?

  • Did the equipment operator sustain any injuries?

  • Injury severity:

  • Did the equipment operator receive medical treatment away from the accident scene?

Other Company - Damages

  • Equipment

  • Damage severity:

  • Shade the areas that suffered damages:

  • Make

  • Model

  • Damage severity:

  • Shade the areas that suffered damages:

  • Make

  • Model

  • Damage severity:

  • Shade the areas that suffered damages:

  • Make

  • Model

  • Damage severity:

  • Shade the areas that suffered damages:

  • Make

  • Model

  • Damage severity:

  • Make

  • Model

  • Other:

  • Damage severity:

  • Make

  • Model

Other Company Information

  • Company Name:

  • Contact Person:

  • Phone #:

Other Party - Injuries

  • Did anyone sustain any injuries as a result of this incident?

  • Injury severity:

  • Did the injured person(s) receive medical treatment away from the accident scene?

Other Company Information

  • Company Name:

  • Contact Person:

  • Phone #:

Other Party - Injuries

  • Did the other party sustain any injuries?

  • Injury severity:

  • Did the other party receive medical treatment away from the accident scene?

Other Party - General Information

  • Name:

  • Address:

  • Phone #:

Other Company Information

  • Company Name:

  • Contact Person:

  • Phone #:

Other Party - Injuries

  • Did anyone sustain any injuries as a result of this incident?

  • Injury severity:

  • Did the injured person(s) receive medical treatment away from the accident scene?

  • Other:

  • Incident with:

Other Party - Injuries

  • Did the other vehicle driver sustain any injuries?

  • Injury severity:

  • Did the other vehicle driver receive medical treatment away from the accident scene?

  • Were there any passengers on the other vehicle?

  • Number of passengers

  • Did any of the passengers in the other vehicle sustain any injuries?

  • Injury severity:

  • Did any passenger on the other vehicle receive medical treatment away from the accident scene?

Other Party - General Information

  • Driver Name:

  • Address:

  • Phone #:

  • Driver License #:

  • State:

Other Party - Vehicle Information

  • Vehicle Make

  • Other:

  • Vehicle Model:

  • Color:

  • License Plate:

  • State:

Other Party - Insurance Information

  • Insurance Company:

  • Policy #:

  • Policy Expiration Date:

Other Party - Damages

  • Did the other vehicle sustain any damages?

  • Damage severity:

  • Shade the areas that suffered damages:

  • Was the other vehicle towed?

  • Other Damages:

  • Shade the areas that suffered damages:

  • Was the Other Vehicle Towed?

Other Party - Injuries

  • Were there any persons occupying the parked motor vehicle?

  • Did any of the persons occupying the parked motor vehicle sustain any injuries?

  • Injury severity:

  • Did any of the persons occupying the parked motor vehicle receive medical treatment away from the accident scene?

Other Party - General Information

  • Driver Name:

  • Address:

  • Phone #:

  • Driver License #:

  • State:

Other Party - Vehicle Information

  • Vehicle Make

  • Other:

  • Vehicle Model:

  • Color:

  • License Plate:

  • State:

Other Party - Insurance Information

  • Insurance Company:

  • Policy #:

  • Policy Expiration Date:

Other Party - Damages

  • Did the other vehicle sustain any damages?

  • Damage severity:

  • Shade the areas that suffered damages:

  • Was the other vehicle towed?

  • Other Damages:

  • Shade the areas that suffered damages:

  • Was the Other Vehicle Towed?

Other Party - Injuries

  • Did the other party sustain any injuries?

  • Injury severity:

  • Did the other party receive medical treatment away from the accident scene?

Other Party - General Information

  • Name:

  • Address:

  • Phone #:

Preliminary Incident Analysis

Sequence of events - List facts in chronological order

    Facts:

Evidence/Reporting

  • Were pictures taken?

  • Did anybody witness the incident?

  • Witness Name:

  • Witness Statement:

  • Witness Phone Number

  • Was this incident reported in a timely manner?

  • Reason given by employee to explain why this incident was reported late?

Incident Cause/Corrective Action

  • Were normal work practices being used?

  • PPE used by the employee at the time of the incident?

  • Other:

  • Given the current information, what is the main cause(s) of this incident?

  • Other:

  • Recommended actions to prevent this incident from recurring?

Supporting Documentation

  • Employee Statement

  • Acknowledgement of Receipt of Claim Form DWC 1 & MPN Information

  • Employee Refusal of Medical Treatment

  • Employee did not receive medical treatment

  • I fully understand, that I'm required to notify the company of any job related accident/incident on the day it occurred and prior to leaving company property, and that failure to do so, or the falsification of a company record will result in disciplinary action up to and including termination. Furthermore, I am signing the above report to be true and correct under the penalty of perjury, if this is a fraudulent claim, I understand I could be prosecuted to the fullest extent of the law.

  • Employee Name:

  • Employee Signature

  • Supervisor Completing Report:

  • Supervisor Signature

  • Have all items relevant to this report been completed?

  • Notes:

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.