Incident Category

  • Incident Date:

  • Incident Time:

  • Type of incident?

  • Owner of property:

  • Relation to job:

Individuals Involved

  • Type of involvement?

  • Name:

  • Address:

  • Phone Number:

  • SCCI or Sub Contractor Employee?

  • Job Number:

  • Crew:

  • Crew Size:

  • Superintendent:

  • Foreman:

  • Occupation:

  • Years in Occupation:

  • Date of Hire:

  • Type of involvement?

  • Phone Number:

  • Name:

  • Address:

  • SCCI or Sub Contractor Employee?

  • Job Number:

  • Crew:

  • Crew Size:

  • Superintendent:

  • Foreman:

  • Occupation:

  • Years in Occupation:

  • Date of Hire:

  • Type of involvement?

  • Name:

  • Address:

  • Phone Number:

  • SCCI or Sub Contractor Employee?

  • Job Number:

  • Crew:

  • Crew Size:

  • Superintendent:

  • Foreman:

  • Occupation:

  • Years in Occupation:

  • Date of Hire:

  • SCCI or Sub Contractor?

Equipment, Tools, Materials and Supplies Involved

Narrative of Incident

Specific Injuries and Part of Body Affected

  • Specific Injuries:

  • Part of Body Affected:

Medical Treatment

  • Declining Medical Attention at this Time?

  • Medical Provider Information:

  • Diagnosis:

  • Work Status:

Approval/Signatures

  • Employee:

  • Safety Manager:

  • Supervisor:

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