Incident/Injury Report 1.1

• Incident/Injury Report

• Location
  Address

• Incident Date and Time

  Date

• Prepared by

Project Information

• Project Name

• Project Number

• Project Address
  Address

• Project Manager and Phone Number

• Project General Foreman and Phone Number

• General Contractor, Contact and Phone Number

General Information

Injured Employee


• Employee Name

• Trade and Level Classification

  Select Pipefitter - General Foreman Pipefitter - Foreman Pipefitter - Journeyman Pipefitter - Apprentice Plumber - General Foreman Plumber - Foreman Plumber - Journeyman Plumber - Apprentice Sheet Metal - General Foreman Sheet Metal - Foreman Sheet Metal - Journeyman Sheet Metal - Apprentice Controls Electrician Controls Apprentice Service Technician Pre-Apprentice Helper

  • Pipefitter - General Foreman
  • Pipefitter - Foreman
  • Pipefitter - Journeyman
  • Pipefitter - Apprentice
  • Plumber - General Foreman
  • Plumber - Foreman
  • Plumber - Journeyman
  • Plumber - Apprentice
  • Sheet Metal - General Foreman
  • Sheet Metal - Foreman
  • Sheet Metal - Journeyman
  • Sheet Metal - Apprentice
  • Controls Electrician
  • Controls Apprentice
  • Service Technician
  • Pre-Apprentice
  • Helper

• Company Employee Works For

  Select Harris Mechanical Harris Mechanical Service HiMec Mechanical HiMec Northfield Harris Service Midwest Fabrication Harris Mechanical Southwest TRAK International Superior Air Handling Harris Superior CA Harris Intermountain Wasatch Controls RM Thornton Mechanical

  • Harris Mechanical
  • Harris Mechanical Service
  • HiMec Mechanical
  • HiMec Northfield
  • Harris Service
  • Midwest Fabrication
  • Harris Mechanical Southwest
  • TRAK International
  • Superior Air Handling
  • Harris Superior CA
  • Harris Intermountain
  • Wasatch Controls
  • RM Thornton Mechanical

• Employee Date of Birth

Description of Injury/Illness?

• Type of Incident

  Select Fall From Height Struck By Falling Object Electrical Shock Burn Engulfment Impalement Laceration Fracture Foreign Body Muscle Strain/Sprain Inhalation Exposure Inhalation Exposure

  • Fall From Height
  • Struck By Falling Object
  • Electrical Shock
  • Burn
  • Engulfment
  • Impalement
  • Laceration
  • Fracture
  • Foreign Body
  • Muscle Strain/Sprain
  • Inhalation
  • Exposure
  • Inhalation
  • Exposure

• Photo(s) of Incident Site

  Media

• Type of Injury?

  Select Sprain/Strain Fracture Laceration Burn Foreign Body Inhalation Abrasion Contusion Electric Shock Chemical Exposure Thermal Injury Crush

  • Sprain/Strain
  • Fracture
  • Laceration
  • Burn
  • Foreign Body
  • Inhalation
  • Abrasion
  • Contusion
  • Electric Shock
  • Chemical Exposure
  • Thermal Injury
  • Crush

• Part of Body Effected

• Left or Right Side, Front or Back, Top or Bottom

  Select Left Side Right Side Front Side Back Side Top Bottom

  • Left Side
  • Right Side
  • Front Side
  • Back Side
  • Top
  • Bottom

• Was a post-incident drug test completed?

  Yes

  No

  N/A

• Was there any damage to equipment?

  Yes

  No

  N/A

• What was the equipment?

• Picture of damaged equipment.

  Media

• Estimated of cost to repair/replace equipment.

Medical Treatment Information

• What type of medical treatment was required?

  Select First Aid - Onsite Self-Administered First Aid - Onsite Assisted First Aid - Onsite Medical First Aid - Offsite Medical Occupational Clinic Treatment Emergency Room Treatment

  • First Aid - Onsite Self-Administered
  • First Aid - Onsite Assisted
  • First Aid - Onsite Medical
  • First Aid - Offsite Medical
  • Occupational Clinic Treatment
  • Emergency Room Treatment

• Name of Treating Medical Service Provider (if Offsite Medical, Clinic, or ER)

• Name and Address of Clinic or Emergency Room

• Clinic or Hospital Phone Number

Incident Statements

Injured Employee Statement

• Employee Statement (describe incident in own words) What happened? How did it happen?

• Photos of Incident Scene

  Media

• Employee Signature

  Sign
Witness Statement

• Witness Statement (describe incident) Who, What, Where, When, Why, How. Be Specific, No Opinions.

• Witness Signature

  Sign

Incident Analysis

• Primary Cause?

• Contributing Factors?

Preventative/Corrective Actions

• Immediate Action Required:

• When should this action be completed by?

  Date

• Who Is Responsible to oversee this action?

• Long Term Action Required:

• Who is Responsible to oversee this action?

• When should this action be completed by?

  Date

Accident Investigation Completed by:

• Signature of person completing this investigation.

  Sign

• Investigation completed

  Date

Follow-up Investigation

• Is a follow-up Investigation required?

  Yes

  No

  N/A

• Has a follow-up investigation been completed?

  Yes

  No

  N/A