Title Page
Incident Information
-
STS Location
- Atlanta (Smyrna)
- Atlanta (Mableton)
- Daytona
- Fort Lauderdale / Miami
- Fort Myers
- Fort Pierce
- Pensacola
- Tampa
- West Palm Beach
-
Company Involved
- STS Incident
- Subcontractor Incident
- Near Miss
- Other
-
911 Called or EMS Respond?
-
Did the police arrive on scene?
-
What is the case # and the police department name?
-
STS Job Name
-
STS Job #
-
Area Manager
- Ryan Tidwell
- Manuel Pedraza
- Joshua Braden
- Rick Castelo
- Brandon Wehner
- Tammy Zanetti
- Ricardo Perez
- Danny Madison
- Dalton Volk
-
Job Site Address
-
Location Where Accident Occurred (If different from Site Address)
-
Reported By:
-
Date of accident
-
Date Reported
-
Time Work Began
-
Incident Type
- Injury/Illness
- Property Damage
- Vehicle/Equipment
- Chemical Spill
- Stolen Property
- Water Damage
- Injury To The Public
- Utility Strike
- Other
-
Was an STS Employee Involved?
-
How many Employees were involved
Employee information
-
What was the name of the employee
-
Was the Employee injured?
-
Severity
-
Body Part Injured
- Head
- Face
- Foot
- Torso
- Hands/Wrists
- Arm
- Shoulder
- Knee
- Back
- Neck
- Face
- Legs
- Eyes
- Ears
- Mouth
Body Diagram
-
Indicate injured areas here
-
Side of Body Injured
-
Type of injury
- Bruising
- Dislocation
- Strain/sprain
- Scratch/abrasion
- Internal
- Fracture
- Amputation
- Foreign body
- Laceration/cut
- Burn/scald
- Chemical reaction
- Other
-
Specify injured part of body
-
What object or substance directly harmed the employee (e.g., sign, tripod, hammer, wrench)?
-
Weight of the Object
-
Did the incident happen inside a work zone?
-
Does the Employee need to seek medical treatment that is beyond basic first aid?
-
Where will the employee be taken to?
-
Please notify the area safety coordinator immediately
-
Please have the employee read and sign the following
-
I acknowledge that I have reported an on-the-job incident. Southeastern Traffic supply has offered me medical attention to be administered by a medical facility, however, at this time I do not require medical attention. By signing this form, I contest that I can safely complete the essential functions of my job without compromising the safety of my co-workers, myself, or the general public. I understand that if my condition changes in relation to this work-related incident I MUST notify the facility's administration BEFORE seeking any medical attention
-
Please type the signed name above
-
Address
-
Date of birth
-
Phone number
-
Job Title
-
Date of Hire
-
Gender
-
Activity in progress at time of incident
-
Was the employee trained?
-
Date
-
List all employees separately
Employee 1
-
What was the name of the employee
-
Was the Employee injured?
-
Severity
-
Body Part Injured
- Head
- Face
- Foot
- Torso
- Hands/Wrists
- Arm
- Shoulder
- Knee
- Back
- Neck
- Face
- Legs
- Eyes
- Ears
- Mouth
Body Diagram
-
Indicate injured areas here
-
Side of Body Injured
-
Type of injury
- Bruising
- Dislocation
- Strain/sprain
- Scratch/abrasion
- Internal
- Fracture
- Amputation
- Foreign body
- Laceration/cut
- Burn/scald
- Chemical reaction
- Other
-
Specify injured part of body
-
What object or substance directly harmed the employee (e.g., sign, tripod, hammer, wrench)?
-
Weight of the Object
-
Did the incident happen inside a work zone?
-
Does the Employee need to seek medical treatment that is beyond basic first aid?
-
Where will the employee be taken to?
-
Please notify the area safety coordinator immediately
-
Please have the employee read and sign the following
-
I acknowledge that I have reported an on-the-job incident. Southeastern Traffic supply has offered me medical attention to be administered by a medical facility, however, at this time I do not require medical attention. By signing this form, I contest that I can safely complete the essential functions of my job without compromising the safety of my co-workers, myself, or the general public. I understand that if my condition changes in relation to this work-related incident I MUST notify the facility's administration BEFORE seeking any medical attention
-
Please type the signed name above
-
Address
-
Date of birth
-
Phone number
-
Job Title
-
Date of Hire
-
Gender
-
Activity in progress at time of incident
-
Was the employee trained?
-
Date
Employee 2
-
What was the name of the employee
-
Was the Employee injured?
-
Severity
-
Body Part Injured
- Head
- Face
- Foot
- Torso
- Hands/Wrists
- Arm
- Shoulder
- Knee
- Back
- Neck
- Face
- Legs
- Eyes
- Ears
- Mouth
Body Diagram
-
Indicate injured areas here
-
Side of Body Injured
-
Type of injury
- Bruising
- Dislocation
- Strain/sprain
- Scratch/abrasion
- Internal
- Fracture
- Amputation
- Foreign body
- Laceration/cut
- Burn/scald
- Chemical reaction
- Other
-
Specify injured part of body
-
What object or substance directly harmed the employee (e.g., sign, tripod, hammer, wrench)?
-
Weight of the Object
-
Did the incident happen inside a work zone?
-
Does the Employee need to seek medical treatment that is beyond basic first aid?
-
Where will the employee be taken to?
-
Please notify the area safety coordinator immediately
-
Please have the employee read and sign the following
-
I acknowledge that I have reported an on-the-job incident. Southeastern Traffic supply has offered me medical attention to be administered by a medical facility, however, at this time I do not require medical attention. By signing this form, I contest that I can safely complete the essential functions of my job without compromising the safety of my co-workers, myself, or the general public. I understand that if my condition changes in relation to this work-related incident I MUST notify the facility's administration BEFORE seeking any medical attention
-
Please type the signed name above
-
Address
-
Date of birth
-
Phone number
-
Job Title
-
Date of Hire
-
Gender
-
Activity in progress at time of incident
-
Was the employee trained?
-
Date
-
List all employees separately
Employee 1
-
What was the name of the employee
-
Was the Employee injured?
-
Severity
-
Body Part Injured
- Head
- Face
- Foot
- Torso
- Hands/Wrists
- Arm
- Shoulder
- Knee
- Back
- Neck
- Face
- Legs
- Eyes
- Ears
- Mouth
Body Diagram
-
Indicate injured areas here
-
Side of Body Injured
-
Type of injury
- Bruising
- Dislocation
- Strain/sprain
- Scratch/abrasion
- Internal
- Fracture
- Amputation
- Foreign body
- Laceration/cut
- Burn/scald
- Chemical reaction
- Other
-
Specify injured part of body
-
What object or substance directly harmed the employee (e.g., sign, tripod, hammer, wrench)?
-
Weight of the Object
-
Did the incident happen inside a work zone?
-
Does the Employee need to seek medical treatment that is beyond basic first aid?
-
Where will the employee be taken to?
-
Please notify the area safety coordinator immediately
-
Please have the employee read and sign the following
-
I acknowledge that I have reported an on-the-job incident. Southeastern Traffic supply has offered me medical attention to be administered by a medical facility, however, at this time I do not require medical attention. By signing this form, I contest that I can safely complete the essential functions of my job without compromising the safety of my co-workers, myself, or the general public. I understand that if my condition changes in relation to this work-related incident I MUST notify the facility's administration BEFORE seeking any medical attention
-
Please type the signed name above
-
Address
-
Date of birth
-
Phone number
-
Job Title
-
Date of Hire
-
Gender
-
Activity in progress at time of incident
-
Was the employee trained?
-
Date
Employee 2
-
What was the name of the employee
-
Was the Employee injured?
-
Severity
-
Body Part Injured
- Head
- Face
- Foot
- Torso
- Hands/Wrists
- Arm
- Shoulder
- Knee
- Back
- Neck
- Face
- Legs
- Eyes
- Ears
- Mouth
Body Diagram
-
Indicate injured areas here
-
Side of Body Injured
-
Type of injury
- Bruising
- Dislocation
- Strain/sprain
- Scratch/abrasion
- Internal
- Fracture
- Amputation
- Foreign body
- Laceration/cut
- Burn/scald
- Chemical reaction
- Other
-
Specify injured part of body
-
What object or substance directly harmed the employee (e.g., sign, tripod, hammer, wrench)?
-
Weight of the Object
-
Did the incident happen inside a work zone?
-
Does the Employee need to seek medical treatment that is beyond basic first aid?
-
Where will the employee be taken to?
-
Please notify the area safety coordinator immediately
-
Please have the employee read and sign the following
-
I acknowledge that I have reported an on-the-job incident. Southeastern Traffic supply has offered me medical attention to be administered by a medical facility, however, at this time I do not require medical attention. By signing this form, I contest that I can safely complete the essential functions of my job without compromising the safety of my co-workers, myself, or the general public. I understand that if my condition changes in relation to this work-related incident I MUST notify the facility's administration BEFORE seeking any medical attention
-
Please type the signed name above
-
Address
-
Date of birth
-
Phone number
-
Job Title
-
Date of Hire
-
Gender
-
Activity in progress at time of incident
-
Was the employee trained?
-
Date
Employee 3
-
What was the name of the employee
-
Was the Employee injured?
-
Severity
-
Body Part Injured
- Head
- Face
- Foot
- Torso
- Hands/Wrists
- Arm
- Shoulder
- Knee
- Back
- Neck
- Face
- Legs
- Eyes
- Ears
- Mouth
Body Diagram
-
Indicate injured areas here
-
Side of Body Injured
-
Type of injury
- Bruising
- Dislocation
- Strain/sprain
- Scratch/abrasion
- Internal
- Fracture
- Amputation
- Foreign body
- Laceration/cut
- Burn/scald
- Chemical reaction
- Other
-
Specify injured part of body
-
What object or substance directly harmed the employee (e.g., sign, tripod, hammer, wrench)?
-
Weight of the Object
-
Did the incident happen inside a work zone?
-
Does the Employee need to seek medical treatment that is beyond basic first aid?
-
Where will the employee be taken to?
-
Please notify the area safety coordinator immediately
-
Please have the employee read and sign the following
-
I acknowledge that I have reported an on-the-job incident. Southeastern Traffic supply has offered me medical attention to be administered by a medical facility, however, at this time I do not require medical attention. By signing this form, I contest that I can safely complete the essential functions of my job without compromising the safety of my co-workers, myself, or the general public. I understand that if my condition changes in relation to this work-related incident I MUST notify the facility's administration BEFORE seeking any medical attention
-
Please type the signed name above
-
Address
-
Date of birth
-
Phone number
-
Job Title
-
Date of Hire
-
Gender
-
Activity in progress at time of incident
-
Was the employee trained?
-
Date
-
List all employees separately
Employee 1
-
What was the name of the employee
-
Was the Employee injured?
-
Severity
-
Body Part Injured
- Head
- Face
- Foot
- Torso
- Hands/Wrists
- Arm
- Shoulder
- Knee
- Back
- Neck
- Face
- Legs
- Eyes
- Ears
- Mouth
Body Diagram
-
Indicate injured areas here
-
Side of Body Injured
-
Type of injury
- Bruising
- Dislocation
- Strain/sprain
- Scratch/abrasion
- Internal
- Fracture
- Amputation
- Foreign body
- Laceration/cut
- Burn/scald
- Chemical reaction
- Other
-
Specify injured part of body
-
What object or substance directly harmed the employee (e.g., sign, tripod, hammer, wrench)?
-
Weight of the Object
-
Did the incident happen inside a work zone?
-
Does the Employee need to seek medical treatment that is beyond basic first aid?
-
Where will the employee be taken to?
-
Please notify the area safety coordinator immediately
-
Please have the employee read and sign the following
-
I acknowledge that I have reported an on-the-job incident. Southeastern Traffic supply has offered me medical attention to be administered by a medical facility, however, at this time I do not require medical attention. By signing this form, I contest that I can safely complete the essential functions of my job without compromising the safety of my co-workers, myself, or the general public. I understand that if my condition changes in relation to this work-related incident I MUST notify the facility's administration BEFORE seeking any medical attention
-
Please type the signed name above
-
Address
-
Date of birth
-
Phone number
-
Job Title
-
Date of Hire
-
Gender
-
Activity in progress at time of incident
-
Was the employee trained?
-
Date
Employee 2
-
What was the name of the employee
-
Was the Employee injured?
-
Severity
-
Body Part Injured
- Head
- Face
- Foot
- Torso
- Hands/Wrists
- Arm
- Shoulder
- Knee
- Back
- Neck
- Face
- Legs
- Eyes
- Ears
- Mouth
Body Diagram
-
Indicate injured areas here
-
Side of Body Injured
-
Type of injury
- Bruising
- Dislocation
- Strain/sprain
- Scratch/abrasion
- Internal
- Fracture
- Amputation
- Foreign body
- Laceration/cut
- Burn/scald
- Chemical reaction
- Other
-
Specify injured part of body
-
What object or substance directly harmed the employee (e.g., sign, tripod, hammer, wrench)?
-
Weight of the Object
-
Did the incident happen inside a work zone?
-
Does the Employee need to seek medical treatment that is beyond basic first aid?
-
Where will the employee be taken to?
-
Please notify the area safety coordinator immediately
-
Please have the employee read and sign the following
-
I acknowledge that I have reported an on-the-job incident. Southeastern Traffic supply has offered me medical attention to be administered by a medical facility, however, at this time I do not require medical attention. By signing this form, I contest that I can safely complete the essential functions of my job without compromising the safety of my co-workers, myself, or the general public. I understand that if my condition changes in relation to this work-related incident I MUST notify the facility's administration BEFORE seeking any medical attention
-
Please type the signed name above
-
Address
-
Date of birth
-
Phone number
-
Job Title
-
Date of Hire
-
Gender
-
Activity in progress at time of incident
-
Was the employee trained?
-
Date
Employee 3
-
What was the name of the employee
-
Was the Employee injured?
-
Severity
-
Body Part Injured
- Head
- Face
- Foot
- Torso
- Hands/Wrists
- Arm
- Shoulder
- Knee
- Back
- Neck
- Face
- Legs
- Eyes
- Ears
- Mouth
Body Diagram
-
Indicate injured areas here
-
Side of Body Injured
-
Type of injury
- Bruising
- Dislocation
- Strain/sprain
- Scratch/abrasion
- Internal
- Fracture
- Amputation
- Foreign body
- Laceration/cut
- Burn/scald
- Chemical reaction
- Other
-
Specify injured part of body
-
What object or substance directly harmed the employee (e.g., sign, tripod, hammer, wrench)?
-
Weight of the Object
-
Did the incident happen inside a work zone?
-
Does the Employee need to seek medical treatment that is beyond basic first aid?
-
Where will the employee be taken to?
-
Please notify the area safety coordinator immediately
-
Please have the employee read and sign the following
-
I acknowledge that I have reported an on-the-job incident. Southeastern Traffic supply has offered me medical attention to be administered by a medical facility, however, at this time I do not require medical attention. By signing this form, I contest that I can safely complete the essential functions of my job without compromising the safety of my co-workers, myself, or the general public. I understand that if my condition changes in relation to this work-related incident I MUST notify the facility's administration BEFORE seeking any medical attention
-
Please type the signed name above
-
Address
-
Date of birth
-
Phone number
-
Job Title
-
Date of Hire
-
Gender
-
Activity in progress at time of incident
-
Was the employee trained?
-
Date
Employee 4
-
What was the name of the employee
-
Was the Employee injured?
-
Severity
-
Body Part Injured
- Head
- Face
- Foot
- Torso
- Hands/Wrists
- Arm
- Shoulder
- Knee
- Back
- Neck
- Face
- Legs
- Eyes
- Ears
- Mouth
Body Diagram
-
Indicate injured areas here
-
Side of Body Injured
-
Type of injury
- Bruising
- Dislocation
- Strain/sprain
- Scratch/abrasion
- Internal
- Fracture
- Amputation
- Foreign body
- Laceration/cut
- Burn/scald
- Chemical reaction
- Other
-
Specify injured part of body
-
What object or substance directly harmed the employee (e.g., sign, tripod, hammer, wrench)?
-
Weight of the Object
-
Did the incident happen inside a work zone?
-
Does the Employee need to seek medical treatment that is beyond basic first aid?
-
Where will the employee be taken to?
-
Please notify the area safety coordinator immediately
-
Please have the employee read and sign the following
-
I acknowledge that I have reported an on-the-job incident. Southeastern Traffic supply has offered me medical attention to be administered by a medical facility, however, at this time I do not require medical attention. By signing this form, I contest that I can safely complete the essential functions of my job without compromising the safety of my co-workers, myself, or the general public. I understand that if my condition changes in relation to this work-related incident I MUST notify the facility's administration BEFORE seeking any medical attention
-
Please type the signed name above
-
Address
-
Date of birth
-
Phone number
-
Job Title
-
Date of Hire
-
Gender
-
Activity in progress at time of incident
-
Was the employee trained?
-
Date
-
List all employees separately
Employee 1
-
What was the name of the employee
-
Was the Employee injured?
-
Severity
-
Body Part Injured
- Head
- Face
- Foot
- Torso
- Hands/Wrists
- Arm
- Shoulder
- Knee
- Back
- Neck
- Face
- Legs
- Eyes
- Ears
- Mouth
Body Diagram
-
Indicate injured areas here
-
Side of Body Injured
-
Type of injury
- Bruising
- Dislocation
- Strain/sprain
- Scratch/abrasion
- Internal
- Fracture
- Amputation
- Foreign body
- Laceration/cut
- Burn/scald
- Chemical reaction
- Other
-
Specify injured part of body
-
What object or substance directly harmed the employee (e.g., sign, tripod, hammer, wrench)?
-
Weight of the Object
-
Did the incident happen inside a work zone?
-
Does the Employee need to seek medical treatment that is beyond basic first aid?
-
Where will the employee be taken to?
-
Please notify the area safety coordinator immediately
-
Please have the employee read and sign the following
-
I acknowledge that I have reported an on-the-job incident. Southeastern Traffic supply has offered me medical attention to be administered by a medical facility, however, at this time I do not require medical attention. By signing this form, I contest that I can safely complete the essential functions of my job without compromising the safety of my co-workers, myself, or the general public. I understand that if my condition changes in relation to this work-related incident I MUST notify the facility's administration BEFORE seeking any medical attention
-
Please type the signed name above
-
Address
-
Date of birth
-
Phone number
-
Job Title
-
Date of Hire
-
Gender
-
Activity in progress at time of incident
-
Was the employee trained?
-
Date
Employee 2
-
What was the name of the employee
-
Was the Employee injured?
-
Severity
-
Body Part Injured
- Head
- Face
- Foot
- Torso
- Hands/Wrists
- Arm
- Shoulder
- Knee
- Back
- Neck
- Face
- Legs
- Eyes
- Ears
- Mouth
Body Diagram
-
Indicate injured areas here
-
Side of Body Injured
-
Type of injury
- Bruising
- Dislocation
- Strain/sprain
- Scratch/abrasion
- Internal
- Fracture
- Amputation
- Foreign body
- Laceration/cut
- Burn/scald
- Chemical reaction
- Other
-
Specify injured part of body
-
What object or substance directly harmed the employee (e.g., sign, tripod, hammer, wrench)?
-
Weight of the Object
-
Did the incident happen inside a work zone?
-
Does the Employee need to seek medical treatment that is beyond basic first aid?
-
Where will the employee be taken to?
-
Please notify the area safety coordinator immediately
-
Please have the employee read and sign the following
-
I acknowledge that I have reported an on-the-job incident. Southeastern Traffic supply has offered me medical attention to be administered by a medical facility, however, at this time I do not require medical attention. By signing this form, I contest that I can safely complete the essential functions of my job without compromising the safety of my co-workers, myself, or the general public. I understand that if my condition changes in relation to this work-related incident I MUST notify the facility's administration BEFORE seeking any medical attention
-
Please type the signed name above
-
Address
-
Date of birth
-
Phone number
-
Job Title
-
Date of Hire
-
Gender
-
Activity in progress at time of incident
-
Was the employee trained?
-
Date
Employee 3
-
What was the name of the employee
-
Was the Employee injured?
-
Severity
-
Body Part Injured
- Head
- Face
- Foot
- Torso
- Hands/Wrists
- Arm
- Shoulder
- Knee
- Back
- Neck
- Face
- Legs
- Eyes
- Ears
- Mouth
Body Diagram
-
Indicate injured areas here
-
Side of Body Injured
-
Type of injury
- Bruising
- Dislocation
- Strain/sprain
- Scratch/abrasion
- Internal
- Fracture
- Amputation
- Foreign body
- Laceration/cut
- Burn/scald
- Chemical reaction
- Other
-
Specify injured part of body
-
What object or substance directly harmed the employee (e.g., sign, tripod, hammer, wrench)?
-
Weight of the Object
-
Did the incident happen inside a work zone?
-
Does the Employee need to seek medical treatment that is beyond basic first aid?
-
Where will the employee be taken to?
-
Please notify the area safety coordinator immediately
-
Please have the employee read and sign the following
-
I acknowledge that I have reported an on-the-job incident. Southeastern Traffic supply has offered me medical attention to be administered by a medical facility, however, at this time I do not require medical attention. By signing this form, I contest that I can safely complete the essential functions of my job without compromising the safety of my co-workers, myself, or the general public. I understand that if my condition changes in relation to this work-related incident I MUST notify the facility's administration BEFORE seeking any medical attention
-
Please type the signed name above
-
Address
-
Date of birth
-
Phone number
-
Job Title
-
Date of Hire
-
Gender
-
Activity in progress at time of incident
-
Was the employee trained?
-
Date
Employee 4
-
What was the name of the employee
-
Was the Employee injured?
-
Severity
-
Body Part Injured
- Head
- Face
- Foot
- Torso
- Hands/Wrists
- Arm
- Shoulder
- Knee
- Back
- Neck
- Face
- Legs
- Eyes
- Ears
- Mouth
Body Diagram
-
Indicate injured areas here
-
Side of Body Injured
-
Type of injury
- Bruising
- Dislocation
- Strain/sprain
- Scratch/abrasion
- Internal
- Fracture
- Amputation
- Foreign body
- Laceration/cut
- Burn/scald
- Chemical reaction
- Other
-
Specify injured part of body
-
What object or substance directly harmed the employee (e.g., sign, tripod, hammer, wrench)?
-
Weight of the Object
-
Did the incident happen inside a work zone?
-
Does the Employee need to seek medical treatment that is beyond basic first aid?
-
Where will the employee be taken to?
-
Please notify the area safety coordinator immediately
-
Please have the employee read and sign the following
-
I acknowledge that I have reported an on-the-job incident. Southeastern Traffic supply has offered me medical attention to be administered by a medical facility, however, at this time I do not require medical attention. By signing this form, I contest that I can safely complete the essential functions of my job without compromising the safety of my co-workers, myself, or the general public. I understand that if my condition changes in relation to this work-related incident I MUST notify the facility's administration BEFORE seeking any medical attention
-
Please type the signed name above
-
Address
-
Date of birth
-
Phone number
-
Job Title
-
Date of Hire
-
Gender
-
Activity in progress at time of incident
-
Was the employee trained?
-
Date
Employee 5
-
What was the name of the employee
-
Was the Employee injured?
-
Severity
-
Body Part Injured
- Head
- Face
- Foot
- Torso
- Hands/Wrists
- Arm
- Shoulder
- Knee
- Back
- Neck
- Face
- Legs
- Eyes
- Ears
- Mouth
Body Diagram
-
Indicate injured areas here
-
Side of Body Injured
-
Type of injury
- Bruising
- Dislocation
- Strain/sprain
- Scratch/abrasion
- Internal
- Fracture
- Amputation
- Foreign body
- Laceration/cut
- Burn/scald
- Chemical reaction
- Other
-
Specify injured part of body
-
What object or substance directly harmed the employee (e.g., sign, tripod, hammer, wrench)?
-
Weight of the Object
-
Did the incident happen inside a work zone?
-
Does the Employee need to seek medical treatment that is beyond basic first aid?
-
Where will the employee be taken to?
-
Please notify the area safety coordinator immediately
-
Please have the employee read and sign the following
-
I acknowledge that I have reported an on-the-job incident. Southeastern Traffic supply has offered me medical attention to be administered by a medical facility, however, at this time I do not require medical attention. By signing this form, I contest that I can safely complete the essential functions of my job without compromising the safety of my co-workers, myself, or the general public. I understand that if my condition changes in relation to this work-related incident I MUST notify the facility's administration BEFORE seeking any medical attention
-
Please type the signed name above
-
Address
-
Date of birth
-
Phone number
-
Job Title
-
Date of Hire
-
Gender
-
Activity in progress at time of incident
-
Was the employee trained?
-
Date
-
Description of incident (state only the facts and do not include assumptions):
-
Was the employee trained?
-
Date
-
Did STS receive a citation for the accident?
-
Project Manager's Name
-
Project Manager's Phone Number
-
What was the Immediate Corrective Action?
Incident/Accident Information
-
Please have all employees involved, handwrite a statement, and add a clear picture of all statements here.
-
Were the employee(s) drug tested?
Damaged Property
-
Was there any property damage?
-
Property or material damaged:
- Property
- Equipment
- STS Vehicle
- Non STS Vehicle
- Trailer
- Buildings and Facilities
-
Nature of damage:
-
Object/substance causing damage:
Lessons Learned
-
How might this incident or other incidents like this be prevented? (Can NOT list ‘by being more careful’)
-
What additional Corrective Actions were put in place? (If necessary)
-
What additional Corrective Actions were put in place? (If necessary)
-
What additional measures might be taken to prevent this type of incident from occurring again?
-
What were the potential consequences of this incident?
Vehicle information
-
Was there a vehicle accident?
-
Who was at fault?
-
Name of the STS Driver
-
Phone Number of the STS Driver
-
Car Make and Model of the STS Driver (ie, Ford F150, Chevy Silverado, etc)
-
Year of Vehicle of the STS Driver
-
STS Vehicle Number
-
STS Vehicle Vin Number
-
Was this accident caused by an STS truck driving in reverse?
-
Did the driver use a spotter?
-
Where was the spotter located when the accident happened?
-
Was another vehicle involved in the accident?
-
Other Vehicle's Driver's Name
-
Other Driver's Phone Number
-
Other Driver's License Number
-
Other Vehicle's Make and Model (ie, Ford F150, Chevy Silverado, etc)
-
Year of Other Vehicle
-
Other Vehicle Vin Number
-
Is The Other Vehicle Insured?
-
Can you take a photo of the other driver's license
-
Take photos of the other partied vehicle
STS Truck Diagram
-
Please indicate areas of damage on STS vehicle
Additional party vehicle Diagram (if needed)
-
Please indicate areas of damage on other parties vehicle if applicable
Additional Information
-
Use this section for other documents
Trailer Diagram
-
Add drawing
