• 1.) Date of Incident

  • 2.) Name of Knife River employee(s) involved

  • Employee
  • Name

  • 3.) Brief Description of Incident by Supervisor

  • Picture of injury and/or damage.

  • Sketch of incident.

  • Rate the seriousness of this incident, 0 = Informational only, 10 = fatality

  • 4.) Location of Incident
  • 5.) Was any Knife River equipment involved?

  • Equipment
  • Make/Model

  • Equipment Number

  • Describe equipment damage

  • Add media

  • 6.) Were any Non Knife River individuals injured?

  • Involved Person
  • Name

  • 7.) Were there any injuries?

  • If the above answer was Yes, then:

  • Injured person
  • Name

  • Describe injury

  • Was first aid administered?

  • If above answer was yes, describe first aid given:

  • Name of person administering first aid:

  • Did injured person see a doctor?

  • If yes, then:

  • Name of doctor, clinic or emergency room

10.) Employee Incident Statement (to be completed by involved employee(s))

  • Employee Statements:

  • Statement
  • Name

  • Add drawing

11.) Actions Taken

  • Corrective and/or disciplinary actions

  • Suggestions to avoid incident from reoccurring

12.) If applicable, supplementary or follow-up incident statements must be completed by:

  • Another Knife River supervisor

  • Name

  • Statement

  • Witness

  • Name

  • Statement

SIGNATURES OF INVOLVED EMPLOYEES:

  • 13.) Knife River supervisor completing form:

  • 14.) Knife River employee(s) involved

  • Employee
  • Name

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