After entering the incident description slide left to access the next step.
Injury / Illness Detail
Does the Incident Involve an Illness or Injury?
Was WorkCare notified @ 1-888-449-7787
What is the Employees Name (Last, First, M.I.)?
Length of service in industry:
Length of service in current position:
Short service employee (SSE)?
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?
- 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
- 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 #:
Operator's license #:
Length of service with UPSL (Aegion):
Length of service in current position in UPSL (Aegion):
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?
- Auto with trailer
- Delivery van
- Heavy truck
- Light truck
- 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:
Was fault admitted or discussed at the scene?
Were police summoned to the scene?
- Both drivers
- Neither drivers
- Other driver
- Our driver
- Police were not summoned
Was our vehicle parked off road at the time of the incident?
Was our vehicle parked legally on a public roadway?
Was our vehicle damaged as part of a theft, road chips, environmental damage, or vandalism?
Was our vehicle tied directly to a work specific function?
Could mileage be reimbursed for this journey?
Was the employee traveling between facilities and not to and from work?
Was our driver improperly licensed or had no license for the vehicle?
Did our driver strike a stationary object?
Did our driver exceed the posted speed limit or was excessive speed a factor?
Was our driver fatigued?
Was our driver distracted due to electronic devices, etc?
What was the source of distraction?
Was our driver in violation of any local laws?
Did our driver receive a citation
Was a poorly secured load a factor in this incident?
Did our driver or any occupants fail to wear seatbelts?
Did our driver fail to complete all required driver training?
Did our driver fail to meet all expectations of the Journey Management policy at the time of the incident (if required)?
Were preventable vehicle defects a factor?
Were any vehicle towed from the scene?
Did any individual leave the incident scene in an ambulance?
Were there any fatalities?
Did any UPSL (Aegion) employee sustain a recordable injury?
Direction of travel:
- Lease road
- On grade
- Parking lot
- Backed into
- Fixed object
- Glass breakage
- Head on
- Hit while occupied
- Other vehicle
- Railroad train
- Ran off road
- Rear ended
- Roll over
- Struck by another
- Head on
- Rear end
Traveling in convoy?
Location of incident:
Street or route:
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.
For motor vehicle incidents complete:
Auto Loss Notice Form
Supervisor Incident report
For Personal injury complete:
Employee's 1st report (DWC-1)
Employer's 1st report (5020)
Supervisors Incident report
Letter to medical provider
Restricted duty form
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?
Once all sections are complete sign below and email your incident investigation to your HSSE department.