Information
-
Employee Name - Incident Report - Location
-
Document No.
-
Client / Site
-
Conducted on
-
Prepared by:
- Mark A. Davis
- Mark D. Davis
- Richard Dickinson
- Anthony Beverly
- Hugh French
- Scott Taylor
- Michael Wright
- James Brown
- Lee Ratliff
- Jason Corbin
- James Shifflett
- Chuck Ayers
- Christopher M. Cole
- Michael Dwyer
- Joe Bailey
-
Location
-
Personnel (List all personnel on site today):
SECTION I
-
Date and time of incident
-
Date and time incident was reported.
-
To whom was the incident reported?
- Mark A. Davis
- Mark D. Davis
- Richard Dickinson
- Anthony Beverly
- Hugh French
- Scott Taylor
- Michael Wright
- James Brown
- Lee Ratliff
- Jason Corbin
- James Shifflett
- Chuck Ayers
- Christopher M. Cole
- Michael Dwyer
- Joe Bailey
-
Location of incident. (Specify site location)
-
Supervisor's Name:
- Mark A. Davis
- Mark D. Davis
- Richard Dickinson
- Anthony Beverly
- Hugh French
- Scott Taylor
- Michael Wright
- James Brown
- Lee Ratliff
- Jason Corbin
- James Shifflett
- Chuck Ayers
- Christopher M. Cole
- Michael Dwyer
- Joe Bailey
-
Supervisor's Phone Number
-
Was there any witness(es)? If yes, provide name(s).
EQUIPMENT INVOLVED
-
Equipment ID Number:
-
Equipment Type:
-
Please take photos of equipment, one picture of the front, rear, left and right sides:
-
Cause of Loss:
- Theft
- Vandalism
- Fire
- Lightning
- Explosion
- Flood
- Other (Explain)
NATURE OF DAMAGE OR INCIDENT
-
Describe damage or incident with as much detail as possible (Include environmental conditions at time of incident):
-
Please take close photos of all damages:
-
Police Department Notified:
-
Police Officers Name(s):
-
Police Officers Badge Number(s):
-
Police Report Number:
-
Fire Department Notified:
-
Estimated Cost of Damage:
-
Environmental photo:
-
Immediate (Direct Causes):
-
Direct Cause Photo:
-
Contributing (Underlying) Factors:
-
Contributing factors photo:
-
Corrective Action (Include Detail Description of Action and Person(s) Responsible for Actions):
-
What is the Probability of Reoccurrance?
-
Appropriate Notifications to Facilitate Repair(s) Have Been Made:
-
Signature of Employee Completing Report:
