Title Page
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This form shall be completed by the DIRECT FOREMAN or MANAGER within 24 hours and returned to Human Resources / Safety
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Employee Name:
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Job Title:
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Jobsite Name and/or Location of Injury:
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Injury Address:
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Person Completing Report:
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Document Number:
Incident Details
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Incident Class:
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Incident Type:
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Date of Incident:
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Time of Incident:
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Date / Time Reported:
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Hours Worked Prior to Incident:
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Incident Cause:
- Unsafe Act (e.g., not wearing PPE)
- Unsafe Condition (e.g., slippery floor)
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Incident Type:
- Sprain / Strain
- Contusion
- Laceration / Avulsion
- Fracture
- Puncture
- Amputation
- Burn / Corrosion
- Foreign Object (i.e., in eye)
- Noise / Hearing
- Respiratory
- Other
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Please describe:
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Description of incident: (Include: tools or equipment in use, task being performed, etc.):
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Description of injury (Include: the type/extent of injury, including specific body part affected):
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Equipment Involved (describe equipment involved: i.e.: type, make, model, power source, etc.):
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Weather Conditions & Temperature at time of incident (describe weather conditions: i.e. sunny/86 F, rainy/43 F, etc.):
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Were there witnesses?
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If YES, list names and complete witness form:
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If YES, list names and complete witness form:
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Was proper PPE used at time of incident?
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Ensure approximately 5 - 10 photos are taken if safe to do so. (i.e., incident scene, background, equipment, etc.)
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Were photos obtained?
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If No, why not?
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Was medical treatment sought?
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If Yes, from whom?
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Name of clinic, hospital, or treating Doctor:
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Treatment was declined at the time of the incident. Have employee sign.
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Was a DOCUMENTED discipline issued to employee?
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If No, why?
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Was injured and/or involved employee(s) sent for drug/alcohol screen?
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If No, why?
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Recommended Corrective Actions:
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L. J. Keefe Co. Representative Signature:
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Date:
