Injury, Accident, Incident Report E Light Electric Service, Inc

• Accident/Incident Title

• Document No.

• Project Name

• Project Number

• Conducted on

  Date

• Reported By:

• Report prepared by:

• Name of Primary person involved:

• Names of other persons involved. Enter each name and their involvement with one word (eg Witness, supervisor, victim) Separate with commas please.

• Location. [Use the Find Me Option and allow GPS locating]
  Address

• Insert pictures. Please be throurough with pictures and ensure that pictures are taken of the area, the damage, the persons involved, and any other item which may help those that were not on scene understand the incident.

  Media

• Add a drawing of the location or other items which may help those that were not on scene understand the incident.

  Drawing

SECTION I

• Name

• Date and time of incident

  Date

• Date and time incident was reported.

  Date

• To whom was the incident reported?

• Location of incident. (Specify site location)

• Was there any witness(es)? If yes, provide name(s).

  Yes

  No

  N/A

DETAILS OF INJURY, IF APPLICABLE

• Describe injury.

• Detail any first-aid or medical treatment administered. (Provide names)

DETAILS OF DAMAGE, IF APPLICABLE

• Property Damage:

  None

  Minor

  Serious

  Major

• Photo of damage.

  Media

• Property Damage:

  N/a

  Vehicle

  Equipment

  Private Property

• Photo of damage.

  Media

• Vehicle ID:

• Detailed description of incident. (Include environmental conditions at time of incident)

• Environmental photo:

  Media

• Immediate (Direct Causes):

• Direct cause photo:

  Media

• Direct cause photo:

  Media

ANALYSIS

• Contributing (underlying) Factors:

• Contributing factors photo:

  Media

• Corrective Action (Include detail description of action and person(s) responsible for actions)

• What was the potential for severity?

  Minor

  Serious

  Major

• What could have potentially happened?

• What is the probability of reoccurrance?

  Remote

  Improbable

  Probable

• Select date

  Date

• Why did the accident happen?

• Why did the answer to the first question happen?

• Why did the answer to the second question happen?

• Why did the answer to the third question happen?

• Why did the answer to the fourth question happen?

• What is the root cause of this accident. One sentence answer.

• What actions are going to be taken to address the root cause of this accident?

• Name and Signature of reporting party

  Sign

• Title of Reporting Party