Incident With Injury

• Prepared by

• Job Number

• Client / Site

• Date and Time of Incident

  Date

• Date and Time Incident Reported

  Date

• Exact Location of Incident

Personnel Involved

• List all employees involved

Employee

• Name

• SSN

• Craft

  Select Carpenter Boilermaker Ironworker Millwright Laborer Operator Teamster Pipefitter

  • Carpenter
  • Boilermaker
  • Ironworker
  • Millwright
  • Laborer
  • Operator
  • Teamster
  • Pipefitter

• Company

  Morrison

  Other

• Other company name

• Employment date

  Date

• Length of time on job

Incident Information

• Give a DETAILED description of the sequence of events up to and including the incident.

• Was anyone injured due to this incident?

  Yes

  No

• List all injured personnel (must also be listed above)

Injured Person

• Name

• Describe the nature of the injury (part of body affected, bleeding, any obvious trauma, what equipment or materials were involved, etc.)

• Photos of all involved equipment, material, etc.

  Media

• Did the injury require treatment beyond on-site first aid (taken to clinic, ambulance called)?

  Yes

  No

• Date and time taken to clinic or released to ambulance

  Date

• Name of clinic or ambulance/hospital

• Name of attending doctor

• Doctor's diagnosis

• What first-aid steps were taken at the time of the injury?

• Did the incident involve property damage?

  Yes

  No

• Describe property damaged

• Photograph(s) of damaged property

  Media

• Approximate cost of property damaged ($)

• Length of downtime of damaged property

• Describe unsafe condition(s) at the time of the incident (be specific).

• Describe the unsafe practice(s) contributing to the incident (be specific).

• List any witnesses.

Witness

• Name

• Company

• What can be done to prevent a recurrence of this incident?

• Signature of person completing the report

  Sign

• Department

• Date report completed

  Date