MCC, INC. - INJURY REPORT

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

ENTER LOCATION OF INJURY BELOW (Include: City, Town and County)

• Add location
  Address

• Select date

  Date

MCC EMPLOYEE NAME AND PH #

ENTER TIME STARTED SHIFT BELOW

• AM

• PM

JOB OR DIVISION

• Mechanic - Enter assigned location below

• Mixer Driver - Enter assigned location below

• Dump or Semi Driver - Enter assigned location below

• Equipment Operator - Enter assigned location below

• Construction

DESCRIBE THE EVENTS LEADING TO INJURY

TYPE OF INJURY

• Sprain

• Strain

• Laceration

• Burn

• Hot or Cold Temp related

• Other - describe type of injury below

LOCATION OF INJURY

• Head and neck

• Lower or Upper Back

• Eye and Face

• LFT Arm and Hand

• RT Arm and Hand

• LFT Leg and Foot

• RT Leg and Foot

MCC DIRECT SUPERVISOR

IS THE INJURY OSHA OR MSHA RECORDABLE

• Anything beyond normal first aid shall be considered recordable per federal regulations

• YES, Enter practitioners information below

• NO

WHO WAS THE INJURY REPORTED TO

WITNESS # 1 INFO

• I hereby agree to the above statement to the best of my eye witness recollection

• Add signature

  Sign

WITNESS # 2 INFO

• I hereby agree to the above statement to the best of my eye witness recollection

• Add signature

  Sign

DRUG TEST REQUIRED

• YES, ENTER BELOW

• Select date

  Date

• NO

ALCOHOL TEST REQUIRED

• YES, ENTER BELOW

• Select date

  Date

• NO

IS A CLAIM BEING FILED

• YES

• NO, NOT AT THIS TIME

ENTER ADDITIONAL INFORMATION BELOW

INJURED PARTY

• I hereby agree with the above information to be accurate, according to gathered statements and observations

• Add signature

  Sign

• Select date

  Date

PERSON FILLING OUT REPORT

• YES I WAS ON SITE OF THE ABOVE ACCIDENT

• I WAS NOT ON-SITE AND ENTERED AFTER THE FACT

• I hereby agree with the above information to be accurate, according to gathered statements and observations

• Add signature

  Sign

• Select date

  Date