Shimmick Incident Report

• Document No.

• Audit Title

• Conducted on

  Date

• Prepared by

• Location
  Address

Incident Category

• Incident Date:

• Incident Time:

• Type of incident?

  Property Damage

  Bodily Injury

  Near Miss

• Owner of property:

  Select SCCI Property 3rd Party

  • SCCI Property
  • 3rd Party

• Relation to job:

  Select SSCI Employee Subcontractor 3rd Party

  • SSCI Employee
  • Subcontractor
  • 3rd Party

Individuals Involved

• Type of involvement?

  Injured Party

  Directly Involved

  Witness

• Name:

• Address:

• Phone Number:

• SCCI or Sub Contractor Employee?

  Yes

  No

  N/A

• Job Number:

• Crew:

• Crew Size:

• Superintendent:

• Foreman:

• Occupation:

• Years in Occupation:

• Date of Hire:

• Type of involvement?

  Injured Party

  Directly Involved

  Witness

• Phone Number:

• Name:

• Address:

• SCCI or Sub Contractor Employee?

  Yes

  No

  N/A

• Job Number:

• Crew:

• Crew Size:

• Superintendent:

• Foreman:

• Occupation:

• Years in Occupation:

• Date of Hire:

• Type of involvement?

  Injured Party

  Directly Involved

  Witness

• Name:

• Address:

• Phone Number:

• SCCI or Sub Contractor Employee?

  Yes

  No

  N/A

• Job Number:

• Crew:

• Crew Size:

• Superintendent:

• Foreman:

• Occupation:

• Years in Occupation:

• Date of Hire:

• SCCI or Sub Contractor?

  SCCI Employee

  Sub Contractor Employee

Equipment, Tools, Materials and Supplies Involved

Narrative of Incident

Specific Injuries and Part of Body Affected

• Specific Injuries:

• Part of Body Affected:

  Select Head Right Ear Left Ear Right Eye Left Eye Nose Mouth Neck Back Chest Right Shoulder Left Shoulder Right Arm Left Arm Right Hand Left Hand Abdomen Hip Right Leg Left Leg Right Knee Left Knee Right Ankle Left Ankle Right Foot Left Foot

  • Head
  • Right Ear
  • Left Ear
  • Right Eye
  • Left Eye
  • Nose
  • Mouth
  • Neck
  • Back
  • Chest
  • Right Shoulder
  • Left Shoulder
  • Right Arm
  • Left Arm
  • Right Hand
  • Left Hand
  • Abdomen
  • Hip
  • Right Leg
  • Left Leg
  • Right Knee
  • Left Knee
  • Right Ankle
  • Left Ankle
  • Right Foot
  • Left Foot

Medical Treatment

• Declining Medical Attention at this Time?

  Yes

  No

  N/A

• Medical Provider Information:

• Diagnosis:

• Work Status:

Approval/Signatures

• Employee:

  Sign

• Safety Manager:

  Sign

• Supervisor:

  Sign