Incident Report

• Site

  Select

• Date of incident

  Date

• Prepared by

• Last name of effected employee

• Incident type

  Select

Employee Information

• Employee's name

• Employee's address

• Employee's department

  Select

• Employee's Date of Birth

• Employee's Date of Hire

• Gender

  Select

Project Information

• Project address

• GC/Client

• This is a joint-venture

• Select one

  Select

Incident Information

• Date and time of incident

  Date

• Date and time the incident was reported

  Date

• Shift start time

  Date

• Shift end time

  Date

• What time did the employee start?

  Date

• Who was the incident reported to?

• Is this a late report? (Not reported on the same day as incident)

  Yes

  No

  N/A

• Employee's immediate supervisor

• Employee's level of experience

  Select

• Location (on jobsite)

Witnesses

• Were there any witnesses present?

  Yes

  No

  N/A

• Please provide witness information. Select "Witness Information/statement" and fill out the section for each witness. Note: Witness statements should be attached to the report. Alternatively, the person filling out the report may complete a narrative--or have the witness complete a narrative--directly in the report and have the witness sign.

Witness Information/statement

• Witness name

• Was a witness statement taken?

  Yes

  No

  N/A

• Witness statement.

• Witness Signature

  Sign

Drug and Alcohol Testing

• Was the employee informed they would need to submit a sample for drug/alcohol testing?

  Yes

  No

  N/A

• STOP!! Drug/alcohol testing is required after any injury/illness and following any property damage or other loss.

• Did the employee submit a sample for drug/alcohol testing? (select "No" for employee refusal)

  Yes

  No

  N/A

• Where did the testing occur?

• When did the testing occur?

  Date

• Results.

  Select

IBEW Status

• Individual is non-union

• Local

  Select

• What is employee's home local?

• This employee is a traveler

• Employee's title

  Select

• Provide information regarding the employee's treatment. This is only required if there was an Injury or Illness (not required for personal medical).

• Describe the injury/illness (i.e. "laceration to left thumb")

• Treatment rendered

  Select

• Was the employee seen/treated in a hospital or other healthcare facility?

  Yes

  No

  N/A

• Employee was treated in an emergency room

• Employee was hospitalized overnight as an in-patient (excluding observation and diagnostics)

• Address of facility

• Doctor or healthcare provider responsible for treatment

• Describe treatment

• This is a preexisting condition

• The information in the section is required by OSHA.

• This is an OSHA Recordable incident

• Select one

  Select

• How long is the employee expected to be out?

• What is the expected return-to-work date?

• Describe the employee's limitations

• Is the employee being transferred to another job/role/location?

  Yes

  No

  N/A

• Describe the employee's transfer

• Describe what made the incident an OSHA recordable.

• When did death occur?

  Date

• Which of the following are most applicable?

  Select

• Describe the illness

• Action being performed when/just before the incident occurred; task

• Event or exposure (i.e. slip/trip/fall, manual lift, climbing ladder)

• Source of injury/illness (i.e. floor, knife, electricity)

• Describe the incident--in chronological order--starting from events leading up to the incident through the control and reporting of the incident. This section should only consist of facts and claims made by the individuals involved. A timeline of events may be helpful.

Narrative

• Describe the actions/inactions of the individuals/things which led up to the events.

• This section is used to record the root cause(s) and contributing factors. There should be at least one root cause and multiple contributing factors.

Root Cause

• Identify a root cause and explain why it is a root cause (verse a contributing factor).

• undefined

Contributing Factor

• Identify a contributing factor and why it is a contributing factor (verse a root cause)

• undefined

• Explain the corrective actions take to reduce the likelihood/eliminate the chances of this incident from reoccurring. Identify responsible parties and set goal completion dates.

Corrective Action

• Describe the corrective action

• Responsible person(s)/parties

• Target completion

  Date

• This item is completed

• Date of completion

  Date

• Identify all attachments that are submitted with the report (either as part of the report or independently but should accompany the report). i.e., photos, documents, videos, etc.

• List of attachments/Supporting documents