WRW Intial Incident Notification

• Audit Title

• Prepared by

• Conducted on

  Date
• Location
  Address

• Select date

  Date

• DAYS INTO SHIFT:

• HOURS INTO SHIFT:

• INCIDENT CLASSIFICATION:

  Select ACCIDENT MIX FUEL DELIVERED TO WRONG LOCATION OTHER

  • ACCIDENT
  • MIX FUEL
  • DELIVERED TO WRONG LOCATION
  • OTHER

• OTHER CHECK BOX INFORMATION:

• INCIDENT#:

• PDS/TMW#:

• CALL TAKER NAME:

• WEATHER CONDITIONS:

• EMPLOYEE TERMINAL#:

• SUBFLEET:

• TRACTOR#:

• TRAILER#:

• YEARS OF SERVICE:

FOR MIX ONLY

• PRODUCT MIX:

• QUANTITY:

• LOCATION:

INJURY INFORMATION

• INJURY TYPE:

• INJURED BODY PART:

• OTHER PARTY INJURY TYPE:

• INJURED OTHER PARTY BODY PART:

• OSHA RECORDABLE

  Yes

  No

  N/A

• PLEASE TAKE AS MANY PHOTOS AS NESSICARY:

  Media

PROPERTY DAMAGE

• PROPERTY DAMAGED : (SPECIFIC DAMAGE TO ALL PROPERTY)

• PLEASE TAKE AS MANY PHOTOS AS NESSICARY:

  Media

INCIDENT INFORMATION:

• LOCATION OF INCIDENT (INCLUDE ADDRESS, CROSS STREETS, MILE MARKERS):

• INCIDENT DESCRIPTION:

• PLEASE TAKE AS MANY PHOTOS AS NESSICARY:

  Media

• OTHER PARTY INVOLVED: NAME, ADRESS, AND PHONE:

• PLEASE TAKE AS MANY PHOTOS AS NESSICARY:

  Media

MANAGER INFORMATION:

• DRUG TEST?

  Yes

  No

  N/A

• REPORTED TO:

  Sign