Incident Report (Without Injury)

• Job Name

• Conducted on

  Date
• Location
  Address

• Business Unit

  Select BC BD BE BM BSG K&N ACI SHOP/YARD

  • BC
  • BD
  • BE
  • BM
  • BSG
  • K&N
  • ACI
  • SHOP/YARD

• Name(s) of employees involved in the incident (First, MI, Last)

Equipment Involved (Budrovich Owned/Rented)

• Equipment involved (Year, Make, Model, Equipment Number)

• Description of Damage to Budrovich Owned Property/Equipment:

Additional Property Damage (Not Budrovich Owned)

• Was there any additional property damaged involved that is not owned by Budrovich? (Building, Vehicles, Equipment, etc.)

  Yes

  No

  N/A

• Owners Name/Phone Number

• Photos Must be take at the time of the incident. (Take thorough photos of the incident, 360 degrees around vehicles)

  Media

Description of Damage

• What was the employee doing when the incident occurred? What operation? What tools? What materials?

• How did the incident occur? Describe all objects, actions and contributing factors.

• What unsafe actions or conditions contributed or caused the incident?

• Was upper management notified immediately?

  Yes

  No

  N/A

• Witness #1 (Name & Phone Number)

• Witness #2 (Name & Phone Number)

• Witness #3 (Name & Phone Number)

• Any Additional Information

• Photos

  Media

• Report Date

  Date

• Report Completed By (Name and Job Title)

• Signature

  Sign

• Email a Copy of the Report to pwineburner@budrovich.com & jmcgill@budrovich.com