Employee Information

  • Department

  • Title

  • Date of hire

  • Date of birth

  • # months in current position

Incident Information

  • Date & Time of incident

  • Amount of time on duty prior to incident

  • Equipment involved

  • Other

  • Equipment #

  • Date and time Supervisor was notified.

  • Specific work method being performed at the time of the incident.

  • How many employee perform this same task?

  • Description of the incident and any injuries, illness or property damage.

  • Have there been similar incidents or near misses prior to this? If yes, explain. If no, mark NA.

  • Did an unsafe act contribute to this incident?

  • If yes, select all that apply from the list below. If no, mark NA.

  • Unsafe Acts

  • Other

Review of Training Records

  • Was training required for this task?

  • Was training required for this task?

  • Was training documented?

  • Describe any 'no' answers or mark NA

Unsafe Conditions

  • Did unsafe conditions contribute to this incident?

  • If yes, mark all that apply below. If no, mark NA.

  • Unsafe Conditions

  • Other

Motor Vehicle Incident Information

  • Truck type

  • Trailer Length

  • Combination vehicle type

  • Truck #

  • Trailer #

  • Driver type

  • Time between routes

  • Nearest city & state

  • Road name/ hwy number

  • Amount of time since last 34 hour break

  • Amount of time since last 10 hour break

  • DriveCam event number

  • DriveCam event history reviewed?

  • Accident history reviewed

  • Traffic violation reviewed?

  • Does this driver meet minimum retention standards?

  • Accident on a public road

  • Injuries?

  • Fatalities?

  • Towed Vehicles?

  • Hazardous Materials Released?

  • Citation issued to company driver?

  • DOT drug test required?

  • DOT drug test completed?

  • If DOT drug test not completed within 32 hours, please explain why.

  • DOT alcohol test required?

  • DOT alcohol test completed?

  • If DOT alcohol test not completed within 8 hours, please explain why.

  • Driving Conditions

  • Other

  • Surface Type

  • Road Configuration

  • Other

  • Traffic Control

  • Other

  • Company Vehicle Action

  • Other

  • Company Vehicle Direction

  • Other Vehicle Action

  • Other

  • Event Type

  • Other

5 Whys

  • Why did the incident occur?

  • Why #2

  • Why #3

  • Why #4

  • Why #5

  • Additional Questions (if needed)

Root Cause Analysis

  • What is the root cause of the incident?

  • List any contributing factors or mark NA

  • List any interim protections or mark NA

  • What are the corrective actions?

  • Who is responsible for the corrective actions?

  • Date Completed

Media

  • Add media

  • Add drawing

Executive Review

  • Supervisor Signature

  • Department Manager Signature

  • Safety Manager Signature

  • VPO/President Signature

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