Title Page
-
Job Name and Number
-
Conducted on
-
Prepared by
-
Location
-
Name of Witness
-
Contact Number:
-
Name of Injured Teammate
Witness Statement
-
Time and Date of Statement
-
Time and Date of Accident
-
Type of Injury:
-
Part of body injured (Arm, Hand, Finger, etc.)
-
What were you doing at the time of the incident?
-
Please explain:
-
What was the injured teammate doing?
-
Please explain:
-
Were you using PPE?
-
Type of equipment being used (Hickey Bar, Choker, etc.)
-
How did this injury happen?
-
Was this hazard covered during the pre-task review?
-
How could this accident have been prevented?
-
Name of immediate foreman:
-
Name of project Superintendent:
-
Please sign
