Incident Report Form

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

• Date/time of incident

  Date

Branch Division

• BSPA

• SOLAR

• BSOH

• SCALO INC

• CUDDY

• HOOD

• NexGen

Type of Incident

• W/C

• G/L

• Auto

• Near Miss

• Other

• Brief Description of Incident

• Name of Employees Involved

If an Injury Occurred Fill Out the Information Below:

• Confirm Injury Reported to Company Nurse

• Name of Injured Employee

• Title/Position

• Home Address

• Employee Phone Number

• Date of Birth

  Date

• Description of Injury

Injury Severity

• First Aid

• Ambulance

• ER

• Clinic

• Name of Hospital/Clinic

• Describe Type of Treatment

• Had the Employee Returned to Duty?

  Yes

  No

  N/A

• Explanation:

General Liability Information:

• Owner information:

• Private

• In-House

• Vehicle

• GC

• Owner Name:

• Company:

• Address:

• Phone Number:

• Point of Contact:

• Describe Property or Vehicle Damage:

• Name of Client You Informed of the Incident(Required!):

• Police or Other Agency Information:

Basic Incident Information

• What was employee doing just before incident occurred?

• What happened? How did incident occur?

• What was the incident?

• What object or substance directly cause the incident?

• Did a fatality occur? (If YES, notify the office immediately!)

  Yes

  No

  N/A

• Date of Death:

  Date

• What could have been done to prevent this incident, and how can it be avoided in the future?

Witness Information:

• Name:

• Phone Number:

• Home Address:

Incidents Reports must be sent to the Director of Safety/Loss Control within 24 hours!

• Date of Report Completed:

  Date

• Report Completed By:

• Signature:

  Sign