Strata Corporation Incident Report

• Time and Date when this report was filled out.

  Date

• Prepared by

• Location
  Address

• Audit Title

• Document No.

• Client / Site

• Strata personnel on site when Incident occured

Detailed information about the Incident

• 1.) Date & Time of Incident

  Date

• Was weather a determining factor in the incident?

  Yes

  No

  Don't Know

• Weather at Time of Incident

  Select Clear Wet Conditions Rain Snow Freezing Rain Light Rain Blizzard

  • Clear
  • Wet Conditions
  • Rain
  • Snow
  • Freezing Rain
  • Light Rain
  • Blizzard

• Temperature at time of incident

  Select - 20 degree's or more -10 to -20 degree's 0 - (-10) degree's 10 - 0 degree's 10 - 20 degree's 20 - 30 degree's 30 - 40 degree's 40 - 50 degree's 50 - 60 degree's 60- 70 degree's 70 - 80 degree's 80 - 90 degree's Greater than 90 degree's

  • - 20 degree's or more
  • -10 to -20 degree's
  • 0 - (-10) degree's
  • 10 - 0 degree's
  • 10 - 20 degree's
  • 20 - 30 degree's
  • 30 - 40 degree's
  • 40 - 50 degree's
  • 50 - 60 degree's
  • 60- 70 degree's
  • 70 - 80 degree's
  • 80 - 90 degree's
  • Greater than 90 degree's

• Wind at time of incident

  0-10

  10-20

  20-30

  30-40

  Greater than 40mph

• 2.) Name of Strata Corporation's employee(s) involved

Employee

• Name

• 3.) Brief Description of Incident by Supervisor

• Picture of injury and/or damage.

  Media

• Sketch of incident.

  Drawing

• Rate the seriousness of this incident, 0 = Informational only, 10 = fatality

• 4.) Location of Incident
  Address

• 5.) Was any Strata Corporation's equipment involved?

  Yes

  No

  Don't Know
Equipment

• Make/Model

• Equipment Number

• Describe equipment damage

• Add media

  Media

• 6.) Were any Non Strata individuals injured?

  Yes

  No

  Don't Know
Involved Person

• Name

• 7.) Were there any injuries?

  Yes

  No

  Don't Know

• If the above answer was Yes, then:

Injured person

• Name

• Describe injury

• Was first aid administered?

  Yes

  No

  Don't Know

• If above answer was yes, describe first aid given:

• Name of person administering first aid:

• Did injured person see a doctor?

  Yes

  No

  Don't Know

• If yes, then:

• Name of doctor, clinic or emergency room

Employee Incident Statement (to be completed by involved employee(s))

• Employee Statements:

Statement

• Name

• Add drawing

  Drawing

Actions Taken

• Corrective and/or disciplinary actions

• Suggestions to avoid incident from reoccurring

If applicable, supplementary or follow-up incident statements must be completed by:

• Another Strata Supervisor

• Name

  Sign

• Statement

• Witness

• Name

  Sign

• Statement

SIGNATURES OF INVOLVED EMPLOYEES:

• 13.) Strata supervisor completing form:

  Sign

• 14.) Strata employee(s) involved

Employee

• Name

  Sign