Title Page
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Date-Initial-Job #
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Name of Injured
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Job name and number
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Conducted on
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Location
1. Date and Time
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Date and Time of Injury:
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Date and Time of Initial Report of Injury:
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Initial Report of Injury made to: (Name, position, and employer)
2. Injured Person Information
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Name of Injured:
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Trade, position, project affiliation:
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Union Affiliation if applicable:
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Injured parties supervisor/foreman:
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Is the injured party an employee of JMCC?
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Indicate the injured person's employer or project affiliation:
3. Injury Type and Description
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Describe the nature and location on the body of the injury: (What the wound looks like and where it is on the body, what you see)
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Injury Photos
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Injured Employees Description of the Injury (Employees quoted description of the injury.)
4. Location of Occurance
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Describe in as much detail as possible the physical location where the incident occurred:
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Location Photos
5. Witness Statements
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Were there any witnesses or personnel working in the area?
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List witnesses and attach their statements here.
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Witnesses
Witness
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Add media
6. Contributing Factors
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Provide a description of the following circumstances and how they played a role in the incident.
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Was a Pre-task plan or Take-5 completed?<br>(Attach Here)
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Describe any work methods or systems and how they played a role in the incident: (e.g. training, unclear work procedures, flow of information)
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Add media
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Describe how the work area or equipment played a role in the incident: (e.g. defective or unsuitable equipment, work area layout or condition)
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Add media
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Describe how environmental conditions may have played a role in the incident: (e.g. noise, lighting, ventilation, temperature, weather)
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Add media
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Describe how any human factors played a role in the incident: (e.g. fatigue, lack of understanding, disregard, malicious intent)
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Add media
7. Treatment Detail
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Was First-Aid provided at the time of the injury?
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Describe the First-Aid provided:
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Was a signed Declination of Treatment Form obtained?
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Declination Form
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Was post incident drug and alcohol testing performed?
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Did the injured person receive care beyond on-site First-Aid?
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Where did the injured person receive treatment?
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What treatment did the injured person receive?
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Was the injured person released to return to work with no restrictions?
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Note any restrictions and required follow up:
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Was a signed Declination of Treatment Form obtained?
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Declination Form
8. Incident Narrative Description
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Provide a detailed narrative of the events and conditions leading up to, during, and after the occurrance.
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Narrative Related Media
9. Corrective Actions
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What actions will be taken to prevent this or a similar injury in the future?
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Corrective Action Photos
10. Signature
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Signature of person conducting the investigation:
