Information
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Incident Number
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Department
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Conducted on
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Investigator
Employee Information
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Name
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Department
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Title
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Interview Date/Time
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Is the above employee a:
Event Fact
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Incident Date/Time
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Event Initiating Investigation Response:
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Other:
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Incident Type
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Was seat belt worn?
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Was driver using a mobile device at the time of the incident?
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Did a Claims Representative arrive at the scene?
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Claims Representative:
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Vehicle/Equipment Involved?
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Vehicle ID
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Event Location
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Weather Conditions
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Utility
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Were KUB property or utilities damaged?
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Were Tennessee One Call marks visible at the site?
Event Description
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Event Description
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Who did you contact regarding the incident?
Mitigation
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Is there anything you think KUB could do to prevent a future incident of this type?
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Can you think of any process updates or training issues that needs to be addressed for improvement?
Sketches
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Provide any sketches necessary to aid in the incident review in the space provided.
Employee Acknowledgment
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Employee Signature By signing this, I certify that I have read this investigation form and have provided all the applicable information.
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Investigator Signature
