Information
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Job Site Name
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Conducted on
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Prepared by
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Location
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Personnel
SECTION I
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Name
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Date and time of incident
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Date and time incident was reported.
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To whom was the incident reported?
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Location of incident. (Specify site location)
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Was there any witness(es)? If yes, provide name(s).
DETAILS OF INJURY, IF APPLICABLE
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Describe injury.
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Photo of injury
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Foremen-Describe what happened
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Injured personnel - Describe what happened
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Witness - Describe what happened
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Detail any first-aid or medical treatment administered. (Provide names)
DETAILS OF DAMAGE, IF APPLICABLE
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Property Damage:
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Photo of damage.
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Vehicle ID:
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Detailed description of incident. (Include environmental conditions at time of incident)
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Environmental photo:
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Immediate (Direct Causes):
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Direct cause photo:
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Direct cause photo:
ANALYSIS
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Contributing (underlying) Factors:
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Contributing factors photo:
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Corrective Action (Include detail description of action and person(s) responsible for actions)
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What was the potential for severity?
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What could have potentially happened?
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What is the probability of reoccurrance?
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Select date
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Signature of foremen
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Signature of injured
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Signature of witness
