Incident Worker's Report

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

• Name of worker(s) involved

• Select date

  Date

• Project name

• Line and Station Number

• Name of Crew Supervisor

Nature of Loss

• Was the worker injured?

  Yes

  No

  N/A

• Did the worker require First-Aid?

  Yes

  No

  N/A

• Was the worker sent to Medical Aid?

  Yes

  No

  N/A

• Attach a copy of the first aid and the doctor's report

• Was equipment damaged?

  Yes

  No

  N/A

• Was third party equipment damaged?

  Yes

  No

  N/A

• For motor vehicle accidents; fill out the GWR auto accident form and attach a copy of the police report if required.

• What was the worker(s) doing?

• Describe the injury or equipment damage.

• Manager/supervisor

  Sign

• Employee

  Sign