J&R Contracting Limited Incident Report

• Client:

• Name of injured party/or person filling out form

• Date and time of incident:

  Date
• Location of incident
  Address

• Job name and number

• Was there any witness(es), if yes, provide names

DETAILS OF INJURY, IF APPLICABLE

• Describe injury.

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

• Detailed description of how injury happened, including cause

DETAILS OF DAMAGE, IF APPLICABLE

• Property Damage:

  None

  Minor

  Serious

  Major

• Photo of damage.

  Media

• Vehicle ID:

• Detailed description of incident / property damage

• What do you think caused incident?

• Signature of person filling out form

  Sign

ANALYSIS - PROJECT MANAGER TO FILL OUT

• 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

• Date investigation completed

  Date

• Signature of Manager

  Sign

• Date Director reviewed

  Date

• Signature of Director

  Sign