Incident Detail
Incident Description:
After entering the incident description slide left to access the next step.
Injury / Illness Detail
Does the Incident Involve an Illness or Injury?
What is the Employees Name (Last, First, M.I.)?
Employee ID:
Length of service in industry:
Length of service in current position:
Job Title
Short service employee (SSE)?
Employment status:
Did the incident result in a fatality?
Was the incident work related?
Would you describe the condition as an injury or illness?
Has/will the employee be unable to attend work for more than 24-hours as a result of this incident or told by a doctor not to return to work?
Has/will the employee need to have his normal duties altered as a result of this incident?
Has the employee received medical treatment beyond first aid?
- Hand
- Arm
- Head
- Eyes
- Legs
- Feet
- Back
- Shoulder
- Abdomen
- Chest
- Groin
- Lungs
- Struck by
- Struck against
- Fall-same level
- Fall-lower level
- Caught in
- Caught by
- Caught between
- Contact with thermal
- Contact with chemical
- Contact with heat
- Contact with electricity
- Overstressed
- Poison
- Skin disorder
- Respiratory condition
- Hearing loss
- Environmental Release
- Equipment failure
Was employee doing his regular job?
Able to work at least (1) full day after date of injury?
If you need to add more than one person on the injury / illness page scroll up and click add for each additional employee. Once you are done with this section slide left to access the next step.
Auto Incident Detail
Would you like to enter an Auto Incident?
Is this a UPSL (Aegion) employee or other driver?
Name (Last, First M.):
Employee ID (UPSL drivers):
Name of company:
Driver contact #:
Address:
Operator's license #:
License class:
Length of service with UPSL (Aegion):
Length of service in current position in UPSL (Aegion):
Position:
Employment status (UPSL drivers):
Insurance company (other driver):
Insurance agent name (other driver):
Insurance telephone # (other driver):
Insurance policy # (other driver):
Who does the vehicle belong to?
- 18-wheeler
- Auto with trailer
- Automobile
- Delivery van
- Heavy truck
- Light truck
- Other
- SUV
- Truck with trailer
Year/make/model of vehicle:
Vehicle license plate #:
Vehicle identification # (VIN):
Names of all passengers involved:
Was driver wearing a seatbelt?
Were passengers wearing seatbelts?
Where may the vehicle be seen?
Describe damage to vehicle:
Speed before incident:
Speed at impact:
Damage to property of others?
Describe damage to property of others:
Equipment description:
Part #:
Part description:
Model #:
Serial #:
If you need to add more than one driver or vehicle scroll up and click add for each additional item. Once you are done with this section slide left to access the next step.
Investigation completion.
For motor vehicle incidents complete:
Auto Loss Notice Form
Members statement
Supervisor Incident report
For Personal injury complete:
Employee's 1st report (DWC-1)
Employer's 1st report (5020)
Supervisors Incident report
Members statement
Letter to medical provider
Restricted duty form
Others:
Property Loss Damage report
General Liability form
Employee injuries that require a doctors visit and all motor vehicle incidents require a drug and alcohol screening with a quick test result.
Have all sections been complete?
