Title Page
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Investigation Title
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Project Number
- 3339F Glenstone
- 4463F Hogan and Lovell
- 4475F NGA
- 5598F 99 M St
- 5611F GMU Academic VII
- 5618F Kennedy Center Expansion
- 5628F RTC BLK 4
- 5630F Walter Reed Forest Glen
- 6635F Leidos
- 6642F Laythem and Watkins
- 6647F 2501 M St
- 6651F Adams center
- 6655F City Market
- 6656F (Base) Fannie Mae
- 6657F (Tennant) Fannie Mae
- 6658F Tysons Galleria
- 6659F Gallery Place FA
- 6662F Ron Brown School
- 6668F United Therapeutics
- 6671F Park Center IV
- 6673F CHP Project Medimmune
- 6676F (Base) DC Bar
- 6679F Hyatt Regency
- 6680F Plaza West
- 6681F Homewood Suites
- 6688F (Base) 655 NY Ave
- 6690F NCE
- 6692F (Tennant) DC Bar
- 6695F Wharf Parcel 1
- 6697F Washington Hilton
- 6698F Providence Sw Gear
- 6699F 1325 G St 7&10 Core
- 6705F L'Enfant Plaza
- 6707F The Moxy
- 6715F Electrical Consolidation Medimmune
- 6716F Washington Adventist
- 6718F Suburban Hospital
- 6718F CEB Tower
- 6719F The Boros
- 6721F Promenade Tower
- 7722F L'Enfant Plaza
- 7724F Macrogenics
- 7727F CSOB4
- 7728F Fish Market
- 7729F AGU
- 7731F FRB I Square
- 7732F Verizon Chesapeake
- 7736F Alarm.com
- 7737F Cath Labs UPS
- 7738F 1500 K St
- 7739F DC United
- 7741F 11th Fl Spec Space Lobby
- 7742F Warrenton Training Center
- 7745F American University
- 7748F Eat Café
- 7749F NCE D Core ATS
- 7750F Regus @ Artisphere
- 7751F Boeing PDU Power
- 7754F GSA
- 7755F Wheatley Baldwin
- 7756F White Flint Upgrades
- 7758F Wizards
- 7759F Yates Field House
- 7760F Cognosante
- 7762F Wakefield HS Renovate
- 7763F Gunston MS Renovate
- 7764F TWO Potomac Yard
- 7766F FA Upgrade
- 7767F NCE Core ATS
- 7768F Amazon Web Services
- 7769F United Health Group
- 7771F NGA Bas Refeed
- OTHER
- Discovery Sterling
- Discovery Silver Spring
- Verizon Baltimore
- Medimmune (Misc)
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Foreman
- Alvarez G
- Arnold R
- Acevedo W
- Bailey D
- Barber C
- Barkley J
- Bath K
- Beach C
- Bennett D
- Benson B
- Brandenburg B
- Breece M
- Brooks C
- Brown L
- Bryant F
- Cassanello Y
- Compofelice D
- Cook L
- Congleton P
- Cowan J
- Cullens E
- Dawson B
- Dean M
- DePhillip C
- Diggle G
- Doherty J
- Ferro M
- Fisher S
- Frillman N
- Gass B
- Groht D
- Hileman T
- Holcomb R
- Kheav V
- Kirk J
- Krahling D
- LaLiberte F
- Lusby T
- Martin J
- McElroy G
- McLain B
- Miller G
- Millsaps D
- Moore S
- Mundy B
- Ness W
- Neylon S
- O'Donnell A
- O'Neil M
- OTHER
- Patrick M
- Pugh J
- Reedy J
- Renner J
- Richards J A
- Ross R
- Ruiz J
- Sample S
- Scully M
- Sharp J
- Shriver K
- Simmons I
- Slattery J
- Smith B
- Smith Jr B
- Templeton J
- Torres J
- Tydings A
- West K
- Williams M
- Wood K
- Wright J
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Project Manager
- Barber C
- Bissett J
- Callow M
- Cassamento P
- Clark C
- Clark D
- Corkhill R
- Daley J
- Diamond M
- Edwards D
- Frew B
- Gerving M
- Gough B
- Huska D
- Jenkins C
- McCoy R
- McPhee M
- OTHER
- Pakla A
- Quigley T
- Reddinger M
- Rhinevault B
- Richards M
- Russell M
- Slate A
- Talton R
- Yuditsky T
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Conducted on
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Prepared by
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Location
Incident Information
Incident Information
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Date/Time of Occurrence
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Incident Type
- Injury
- Illness
- Fire
- Automobile
- Property Damage
- Near Miss
- Spill/Leak/Release
- Other
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Name of Injured
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Employee Classification
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Injury Type
- Report Only
- First Aid
- OSHA Recordable
- OSHA DART
- OSHA Lost Time
- Fatality
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Specific Location of Incident
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Treatment Location
Witness Information
Witness Information
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Has the Injured Person's statement been reviewed and turned into the office?
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Has the Foreman's incident report been reviewed and turned into the office?
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Witness
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Name
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Employer
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Employee Classification
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Phone Number
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Has this witness's statement been reviewed and turned into the office?
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Witness
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Name
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Employer
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Employee Classification
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Phone Number
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Has this witness's statement been reviewed and turned into the office?
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Witness
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Name
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Employer
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Employee Classification
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Phone Number
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Has this witness's statement been reviewed and turned into the office?
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Witness
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Name
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Employer
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Employee Classification
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Phone Number
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Has this witness's statement been reviewed and turned into the office?
Incident Details
Incident Details
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Briefly describe the incident
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Photos
Task Description
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What was the task?
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Who was assigned to the task, and who was in charge?
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How many people were in the crew?
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What was being used to complete the task?
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What hazards existed or were created as part of this task?
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Was a Pre-Task Plan conducted for this task?
Conclusions
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Root Cause(s)
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What could have prevented this incident?
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Recommendations
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What follow up actions have been conducted or are required?
Summary
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Has the General Contractor and/or Customer been notified of the incident?
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Who was involved in the investigation?
- JE Richards Safety Professional
- Foreman
- Project Manager
- Other JE Richards Employee
- General Contractor Safety Professional
- Other General Contractor Representative
- OTHER (Describe Below)
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Who else was involved in the investigation?
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Additional comments
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Investigator signature
