Woods Construction Accident Report

ATTENTION Prior to filling out this Accident Report: 1. Secure the scene of the accident 2. Provide treatment 3. Call for emergency services if necessary 4. Take pictures of the scene

• Name of Injured Employee

• Client / Site

• Conducted on

  Date

• Prepared by

INSTRUCTIONS

• 1. Provide immediate medical attention if necessary. Call Carl or Payroll immediately to authorize treatment/drug testing. Drug/Alcohol test is required for all employee injuries.
  
  2. Within 8 hours, complete this form and the form: 'Root Cause Analysis (Fishbone)' for all job related injuries AND near misses.
  
  3. Whenever possible, the foreman and the injured employee will sign the form.

INFORMATION ABOUT THE INJURED

• Name

• Sex

  Male

  Female

• Date of Hire

  Date

• Date of Birth

  Date

• Home Address

• Phone

• Social Security Number

• Job Title

• What time did the Employee begin work?

  Date

• Did the Employee leave work?

  Yes

  No

• What time?

  Date

• Did the Employee return to work?

  Yes

  No

• What time?

  Date

• Did you authorize medical treatment?

  Yes

  No

• Have restrictions been given?

  Yes

  No

• How long?

• Describe restrictions

• Is there light duty work available?

  Yes

  No

• Fatality?

  Yes

  No

• CALL CARL IMMEDIATELY!

• Were three or more employees injured?

  Yes

  No

• CALL CARL IMMEDIATELY!

• Drug/alcohol test?

  Yes

  No

• THIS IS REQUIRED. CALL MAIN OFFICE IF YOU HAVE ANY QUESTIONS.

INFORMATION ABOUT THE ACCIDENT

• Date and time of the accident

  Date

• Date accident is being reported

  Date

• JOB INFORMATION

• Location Name

• Describe specific location of incident on job site

• Job Number

• Address
  Address

• Foreman

• Describe what happened and probable cause of accident

• 

• Select location of injury and answer the appropriate questions.

  Select 1 HEAD 2 NECK 3 SHOULDER 4 CHEST 5 STOMACH 6 ABDOMEN 7 UPPER ARM 8 ELBOW 9 LOWER ARM 10 HAND 11 HIPS, PELVIS, UPPER LEG 12 KNEE 13 LOWER LEG 14 ANKLE 15 FOOT 16 UPPER BACK 17 MID BACK 18 LOWER BACK 19 BUTTOCKS, TAILBONE

  • 1 HEAD
  • 2 NECK
  • 3 SHOULDER
  • 4 CHEST
  • 5 STOMACH
  • 6 ABDOMEN
  • 7 UPPER ARM
  • 8 ELBOW
  • 9 LOWER ARM
  • 10 HAND
  • 11 HIPS, PELVIS, UPPER LEG
  • 12 KNEE
  • 13 LOWER LEG
  • 14 ANKLE
  • 15 FOOT
  • 16 UPPER BACK
  • 17 MID BACK
  • 18 LOWER BACK
  • 19 BUTTOCKS, TAILBONE

• Describe nature of injury

• Side

  Right

  Left

• Provide pictures of the scene

  Media

• Name of physician and hospital where treated

• Name and phone number of Witness #1

• Name and phone number of Witness #2

• Foreman's Signature

  Sign

• Injured Employee's Signature

  Sign