Incident Report Form

• Site conducted

  Select

• Conducted on

  Date

• Prepared by

• Injured name

• Location
  Address

• Was it our company's employee or subcontractor

  Yes

  No

  N/A

• Who do they work for?

• Incident Category

  Select Injury/ Illness Near Miss Hazard Death Other

  • Injury/ Illness
  • Near Miss
  • Hazard
  • Death
  • Other

1. Injured Person (if applicable)

• Name

• DOB

  Date

• Sex

  Male

  Female

• Contact Number/ Email

• Home address
  Address

• Date of hire

  Date

• Social #

• Take photo of injured person (where appropriate)

  Media

2. Job Details (if applicable)

• Job Title

• Location of job site

• Job Number

• Crew Leader or Direct Supervisior

• Start time

  Date

• Hours worked

  8 hours or less

  More than 8 hours

3. Injury / Incident Details

• When did it occur?

  Date

• When was it reported?

  Date

• Who reported it?

• What was the employee doing just before the incident occurred?

• What happened? (How the injury occurred)

• Was a death involved?

  Yes

  No

• This is REPORTABLE to OSHA within 8 hours from time of death.

• Type of injury?

  Select Laceration Fracture Sprain Amputation Eye Injury Other

  • Laceration
  • Fracture
  • Sprain
  • Amputation
  • Eye Injury
  • Other

• What is the other type of injury?

• Which eye was injured?

  Select Left Right

  • Left
  • Right

• Did this result in the loss of a eye?

  Yes

  No

  N/A

• This is REPORTABLE to OSHA within 24 hours to injury.

• This is a OSHA RECORDABLE on the 300 Log. (Unless hospitalized then it is a REPORTABLE)

• What was amputated?

• This is REPORTABLE to OSHA within 24 hours from time of injury.

• Was treatment beyond first aid? If so this is a OSHA RECORDABLE on the 300 Log.

• This is a OSHA RECORDABLE on the 300 Log. (Unless hospitalized then it is a REPORTABLE)

• Injury location

• Methos of Injury

  Struck by

  Caught in/between

  Falls

  Electrocution

• What directly caused the injury?

• Take/ upload photo evidence of incident, environment, person(s) involved

  Media

4. Treatment or Follow up

• OSHA Recordable
  Any work-related injury or illness that results in loss of consciousness, days away from work, restricted work, or transfer to another job.
  Any work-related injury or illness requiring medical treatment beyond first aid.
  Any work-related diagnosed case of cancer, chronic irreversible diseases, fractured or cracked bones or teeth, and punctured eardrums.

• Was medical treatment required?

  Yes

  No

• Where was the treatment?

  On site

  Urgent Care

  Emergency Room

  Other

• What is the Name and location of Urgent Care?

• How was the worker transported?

  Company truck

  Personal Vehicle

  Ambulance

  Other

• Who transported the employee?

• Why did the employee take his own vehicle?

• Did anyone go with the employee?

  Yes

  No

  N/A

• Who was it?

• Why did the employee travel alone?

• What Ambulance transported the worker?

• Where was the worker transported?

• What is the Name and location of the Emergency Room?

• How did injured person get transported?

• What was the treatment?

• Was there a lost of time worked?

  Yes

  No

• How long of time was lost?

• When is or can the employee return to work

  Date

• Was worker put on restricted duties or restrictions?

  Yes

  No

• How long is the restricted duties?

• When is or can the employee return to normally duty

  Date

• Was employee hospitalized (admitted) overnight as an in-patient?

  Yes

  No

• How long was the employee hospitalized?

• This is REPORTABLE to OSHA within 24 hours to injury.

• Date reported to regulatory authority (leave blank if not required)

  Date

5. Witness Statements (if applicable)

Witness

• Name

• Contact

• Statement

• Witness signature (if applicable)

  Sign

6. After action and Root Cause

• Was there a Fall?

  Yes

  No

• What height?

• Was proper fall protection being used?

  Yes

  No

  N/A

• Was there a violation?

  Yes

  No

• What was the violation?

• All Equipment must be returned to Matt Magrisi - Safety Coordinator ASAP.

• What type of system was being used? (In depth)

• Was the worker wearing PPE?

  Yes

  No

  N/A

• What PPE would they have needed to wear to protect from injury?

• Was the employee issued or had PPE available to them?

  Yes

  No

  N/A

• What PPE were they wearing?

• Was the PPE adequate protection?

  Yes

  No

  N/A

• Recommended action?

• Narrative of Incident

• Process for mitigation of further injuries?

7. Completion

• Name of person completing report?

• Signature of reporting person

  Sign