Injury, Accident, Incident Report

• Prepared by

• Job site (includes driving to or from)

  Select

• Date of incident

  Date

• When was this reported (Safety Culture or phone call

  Date

• Injury, Accident, Incident

  Select Injury (person suffered injury) Accident (no injury, damage occurred Incident (no injury, no damage, reporting only)

  • Injury (person suffered injury)
  • Accident (no injury, damage occurred
  • Incident (no injury, no damage, reporting only)

SECTION I

• Name of those involved

• Date and time incident was reported.

  Date

• To whom was the incident reported?

  Select

• Location of incident. (Specify site location on the job site)

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

  Select

DETAILS OF INJURY, IF APPLICABLE

• Was MEDCOR contacted? 1-844-716-1520

  Select

• 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:

  Select

• What was damaged?

  Select Windshield/ Glass windows Body of vehicle damaged Mechanical Other

  • Windshield/ Glass windows
  • Body of vehicle damaged
  • Mechanical
  • Other

ANALYSIS

• Contributing (underlying) Factors:

  Select

• Corrective Action (what needs to be done or improved)

• What was the potential for severity?

  Minor

  Serious

  Major

• What could have potentially happened?

• What is the probability of reoccurrance?

  Remote

  Improbable

  Probable

• Signature

  Sign

• Date and time of approval

  Date

• Approver's signature

  Sign