Union Power Cooperative Incident Report Form

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

Employee Information

• Employee in charge at the scene

• Crew members at scene

• Employee(s) involved in incident

Location and Time Information

• Address of Incident

• Location # of Incident

• Date of Incident

  Date

• Time of Incident

• Date Incident Reported to Supervisor

  Date

Incident Information

• Type of Incident

  Uncontrolled Release of Energy

  Equipment Damage

  Personal Injury

  Vehicle Accident

  Property Damage

• If Personal Injury, What Body Parts(s) Incurred Injury(s)?

• Any Damage to Equipment?

  Yes

  No

  N/A

• Describe Equipment Damage

• Where Safety Procedures Being Followed?

  Yes

  No

  N/A

• Could Incident Have Been Avoided?

  Yes

  No

  N/A

• Weather Conditions

  Select Sunny Overcast Dark Raining Breezy Fog Hot Cold Moderate Snow/Sleet High Winds Frost Wet

  • Sunny
  • Overcast
  • Dark
  • Raining
  • Breezy
  • Fog
  • Hot
  • Cold
  • Moderate
  • Snow/Sleet
  • High Winds
  • Frost
  • Wet

• UPC Vehicles at the Scene

• Machine, Tool, or Equipment Causing Incident

• Full Description of Incident

• Action Taken to Prevent Recurrence

• Other Company(s) or People Involved?

  Yes

  No

  N/A

• Names and Phone Numbers

• Investigation Team

Medical Information

• Did Injury Require More Than Basic First Aid?

  Yes

  No

  N/A

• What Doctor/Treatment Facility Treated Employee?

• Drug and Alcohol Testing Required?

  Yes

  No

  N/A

• Was Injury OSHA Recordable?

  Yes

  No

  N/A

• Federated Notified?

  Yes

  No

  N/A

Signatures

• Signature of Employee Involved or Employee in Charge

  Sign

• Safety Director Signature

  Sign