Title Page
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User Location
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Conducted on
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Employee submitting:
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Division
- TIA
- Maintenance
- Build Crew
- Civil
- DAS
- Electrical
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Type of Event
- Good Catch
- Near Miss
- Injury
- Theft
- Property Damage
- Vehicle Accident
- Utility Strike
- Significant Safety Violation
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Feeder crew working on:
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Feeder crew working on (if applicable):
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Feeder crew working on:
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The utility owner must be contacted within an hour
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Employee must complete a drug and alcohol screening within 2 hours
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Did the employee complete a police report?
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Employee must complete a drug and alcohol screen within 2 hours of the event.
Event Information
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Crew Member(s) involved
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Foreman of crew
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Describe in detail what happened. (Detailed description NOTE: You can use the voice command feature)
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Add photo(s) of the incident (if applicable). Photos shall be added for all vehicle accidents (all four sides of any vehicles involved), Utility Strikes, Good Catches, Near Misses and Property Damages
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What repairs were made?
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Add photo(s) of any repairs made (if applicable)
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How could the event been prevented? (Detailed description NOTE: You can use the voice command feature)
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