Information

  • Brief Description and Location

  • Prepared by

Project Information

  • Project Name

  • Tuttle Project Manager

  • Tuttle Site Superintendent

  • Has Owner or Client been Notified?

Worker Involved or Injured

  • Employee Last Name

  • Employee First Name

  • Phone Number

  • Date of Birth

  • Date of Incident or Injury

  • Time of Incident or Injury

  • Craft or Job Title

  • Company

  • Age

  • Incident Classification

  • Number of Restricted Days (Maximum 180)

  • Number of Lost Time Days (Maximum 180)

Description of Injury/Illness?

  • Describe the Event in Detail

  • Type of Injury

  • Photo(s) of Incident Site

  • Body Part Injured

  • Left or Right Side, Front or Back, Top or Bottom

  • Type of Event

  • Agency of Event

  • Was there any damage to equipment?

  • What was the equipment or property?

  • Photos of damaged equipment or property.

  • Estimated of cost to repair/replace equipment or property.

  • Was a post-incident drug test completed?

Medical Treatment Information

  • Where was medical treatment provided?

  • Name of Treating Medical Service Provider (if Offsite Medical, Clinic, or ER)

  • Address of Clinic or Emergency Room

  • Clinic or Hospital Phone Number

Cause or Causes

  • Select the Cause or Causes

Incident Statements

    Injured Employee Statement
  • Employee Statement (describe incident in own words) What happened? How did it happen?

  • Photos of Incident Scene

  • Employee Signature

  • Witness Statement
  • Witness Statement (describe incident) Who, What, Where, When, Why, How. Be Specific, No Opinions.

  • Witness Signature

Preventive/Corrective Actions

  • Corrective Action Required:

  • When should this action be completed by?

  • Who Is responsible to oversee this action?

  • Corrective Action Required:

  • When should this action be completed by?

  • Who Is responsible to oversee this action?

  • Corrective Action Required:

  • When should this action be completed by?

  • Who Is responsible to oversee this action?

  • Long Term Action Required:

  • When should this action be completed by?

  • Who is responsible to oversee this action?

  • Long Term Action Required:

  • When should this action be completed by?

  • Who is responsible to oversee this action?

Training Required?

  • Please indicate if training is required and the type required.

Disciplinary Action?

  • Please select the appropriate response

  • Please indicate what disciplinary action if any

Accident Investigation Completed by:

  • Signature of person completing this investigation.

  • Investigation completed

Follow-up Investigation

  • Is a follow-up Investigation required?

  • Has a follow-up investigation been completed?

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.