USSW Incident Report Non Vehicle V1

• Site conducted

  Select

• Conducted on

  Date

• Prepared by

• Describe Injury or Damage to Equipment

• Hospitalization Required

  Yes

  No

  N/A

• Near miss

• Recordable

• Property

• General Liability

• First Aid

• Lost Time Rec

• Fatality

• Other?

Claimant Information

• Claimant Name

• Claimant Address

• Claimant Date of Birth

• Claimant Date of Hire

• Claimant Marital Status

• No. of Dependents

• Employee Occupation

• Hourly or weekly wage

• Hours worked this week

• Employee ID number

• Employee Phone Number

Type of Work being performed

• Describe work being Performed

Type of Injury

• Abrasion

• Allergy

• Burn

• Contusion

• Crush

• Fracture

• Insect Bite

• Laceration

• Multiple

• Pinch

• Puncture

• Sprain/Strain

• Other

Body Part

• Ankle

• Abdomen

• Arm(s)

• Back

• Elbow(s)

• Eye(s)

• Face

• Finger(s)

• Foot

• Hand(s)

• Head

• Hip

• Knee(s)

• undefined

• Leg(s)

• Neck

• Shoulder

• Toe(s)

• Wrist(s)

Cause of Injury

• Caught Between

• Fall

• Improper use or method

• Lifting

• Material Handling

• Slip/Trip

• Struck by Falling Object

• Struck by Moving Equipment

• Use of Equipment

• Use of Tools

• Other

Chronological Sequence of Events (including prior activity)

• Sequence of Events

• Contributing Causes

Attachments

• Was risk assessment JHA completed?

  Yes

  No

  N/A

• Employee Statement

  Yes

  No

  N/A

• Witness Statement

  Yes

  No

  N/A

• Photos,Diagrams

  Yes

  No

  N/A

• Training Records

  Yes

  No

  N/A

• Other

Contact Information (Name and Phone Number)

• Report Prepared By

• Project Manager

• Superintendent

• Foreman

• Witness

• Witness

Employee/Injured Party Statement

• Description of Incident

• Employee/Injured Name and phone number

Witness Statement

• Description of Incident

• Witness Name and phone number

Lessons Learned/Actions Taken

• What lessons were learned and what corrective actions taken?

• Yes

  No

  N/A