Information
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Client / Site
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Location
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Conducted on
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Conducted by
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Type of incident being investigated
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What to Do
If you are involved in an accident, remember to:
1. Get name, address, phone number, driver’s license number, make of vehicle(s), license plate number and names of any passengers and witnesses.
2. DO NOT admit fault.
3. Carefully examine damage to other vehicle(s) involved.
4. Discuss the accident only with police.
5. Obtain a police report at the scene if possible.
6. File claim immediately with your insurance carrier.
Description of Accident
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Location of incident:
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Date/Time of incident:
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Weather Conditions
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Date/Time incident was reported:
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Was the incident reported in a timely fashion?
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Explain why the incident was not reported in a timely fashion:
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Did police office investigate?
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Name / Badge #:
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Was a traffic citation issued?
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Who was the citation issued to and what was it for:
SM Hentges Vehicle Information
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Driver Name
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Employee ID #:
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Department:
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Job Title:
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SM Hentges Vehicle year, make and model:
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SM Hentges Vehicle Plate #:
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Description of damage to the SM Hentges vehicle:
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Was the vehicle being used for Business or Personal Use?
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Include name of company representative that authorized personal use of the vehicle:
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Were there any passengers in the vehicle?
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Include names/ and contact information of passengers:
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Were there any injured persons in the SM Hentges vehicle?
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Include names/ and contact information of passengers:
Other Vehicle Information:
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Driver Name
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Other Vehicle year, make and model:
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Other Vehicle Plate #:
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Description of damage to the Other vehicle:
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Were there any passengers in the Other vehicle?
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Include names/ and contact information of passengers:
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Were there any injured persons in the Other vehicle?
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Include names/ and contact information of passengers:
Witness Information:
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Witness name(s)/contact information
Description of incident - what happened?
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Description of what happened:
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Include multiple photographs of the vehicles involved and the damage
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Include a sketch of the accident scene (optional).
General Information
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Location of incident:
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Date/Time of incident:
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Date/Time incident was reported:
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Was the incident reported in a timely fashion?
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Explain why the incident was not reported in a timely fashion:
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List the employees/companies involved in the incident:
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Were there any witnesses to the incident?
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Include name, company and contact information for any witnesses:
Description of incident - what happened?
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Description of what happened:
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List the equipment that was involved in the incident:
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Description of property damage/severity:
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Include multiple photographs of any equipment involved and the damage
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Include a sketch of the accident scene (optional).
Root Cause Analysis - why did it happen?
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What caused the incident, why/how did it happen?
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Primary Root Cause:
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Contributing Factors:
Preventive/Corrective Action - what will be done to prevent reoccurrence?
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Immediate Corrective Action Taken:
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Long Term Corrective Action Taken:
Notes / Additional Information:
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Additional information, photographs, etc.
Signatures:
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Employee involved:
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Supervisor / Person completing investigation:
General Information
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Location of incident/injury:
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Date/Time of incident/injury:
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Date/Time incident/injury was reported:
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Was the incident/injury reported in a timely fashion?
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Explain why the incident/injury was not reported in a timely fashion:
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Employee Name:
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Employee ID #:
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Employee Department:
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Employee Job Title:
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Job being performed at time of incident/injury
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Were there any witnesses to the incident/injury?
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Include name, company and contact information for any witnesses:
Description of Injury/Illness - what happened?
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Description of what happened:
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Description of injury and severity:
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Treatment provided:
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Name of hospital/clinic and treating physician:
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Discuss the injury with the employee, explain that reporting job-related injuries entitles injured workers to certain benefits while recovering from the injury. If the employee does not wish to receive treatment, have the employee review the next section and sign the investigation form. Immediately notify your supervisor of the incident and the employee's refusal.
Employee statement of refusal of medical treatment:
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I hereby acknowledge my refusal of medical treatment and/or observation offered to me at the expense of SM Hentges for the work-related injury I incurred . By signing this form, I realize that I do not necessarily affect my later eligibility for Workers’ Compensation. I acknowledge that my supervisor(s), in good faith, have offered and made available to me an opportunity to seek necessary medical treatment and/or observation.
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Signature of injured employee:
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Select date
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Statement from the employee:
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Statement from witness/witness(es), include names of those providing statements:
Root Cause Analysis - why did it happen?
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What caused the incident, why/how did it happen?
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Primary Root Cause:
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Contributing Factors:
Preventive/Corrective Action - what will be done to prevent reoccurrence?
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Immediate Corrective Action Taken:
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Long Term Corrective Action Taken:
Notes / Additional Information:
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Additional information, photographs, etc.
Signatures:
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Injured employee:
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Supervisor / Person completing investigation:
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For Emergency Damage – FIRST call 911
Natural gas, high voltage electrical, fire/explosion hazards
Protect public safety THEN call 811 to report facility damage. -
For Non Emergency Damage – Call 811
Telephone, cable, conduits, communication lines, low voltage, sewer laterals, drain lines -
Date and time the utility was damaged:
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Type of utility that was hit?
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Who did you notify?
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Digger / Locate #:
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Name of Locator / Company:
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Utility Owner:
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Date and time the utility owner was notified:
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Was the utility properly located prior to Hit?
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Provide a description of what was not located properly
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Add photo's of damage and the location of utility marks (include something in the photos to provide scale, such as a shovel, cone, etc.)
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We're repairs conducted while you were present?
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Time Repairs were Started:
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Time Repairs were completed:
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Job cost code:
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Estimated Delay/ Down time:
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Number of employees on site making repairs:
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What company performed the repairs?
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Equipment/materials used to make the repairs
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Add photo's of repair personnel and equipment used.
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Names & Phone numbers for witnesses on site:
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Foreman's Signature & Date:
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For Office Only: Date Received: _______________ By:___________________________________ Who will follow up? ______________________________________________________ Will this Become an Insurance Claim? ___________ What Corrective Measures are Warranted to Prevent in Future? _______________________________________________________________________
