Incident Report

• Document No.

• Drees Custom Homes Bodily Injury Report

• Division

• Subdivision

• Prepared by

• Your position

• Your phone number

• Conducted on

  Date
• Location
  Address

Incident must be reported immediately. If possible, pictures must be collected to submit to insurance or other parties. Report must be submitted to: Dianne Walter, Operations Administrator, The Drees Company email: dwalter@dreeshomes.com phone: 859 578 4253

Incident

• Type of incident

  Select Bodily Injury Auto Accident Subcontractor injury

  • Bodily Injury
  • Auto Accident
  • Subcontractor injury

• Date of the incident

  Date

• Submitted to Safety

  Date

Details of person involved

• Name of party involved

• Address of party involved

• Street:

• City:

• State

• Zip Code:

Details of occurrence:

• Location

  Select Customer's Home Home Under Construction Other

  • Customer's Home
  • Home Under Construction
  • Other

• Address of occurrence

• Street:

• City:

• State

• Zip Code:

• Job No. If known

• Describe the occurrence in detail

• Was medical attention given?

  Yes

  No

  N/A

• Describe the treatment given and by whom

• Was the person involved attended to by paramedics or transported to the hospital

  Yes

  No

  N/A

• Please describe

• Please add any supporting photos

  Media

Witnesses:

• Enter witnesses

Witnesses

• Name of witness

• Address of witness

• Street:

• City:

• State

• Zip Code:

Accident Causes:

• Indicate primary incident cause, and explain reason selected: