Date and time of incident

Date and time incident was reported.

To whom was the incident reported?

Location of incident. (Specify site location)

Supervisor's Name

Supervisor's Phone Number

Was there any witness(es)? If yes, provide name(s).

Name (Person 1):

Phone:

Sex:

Age;

Job Title:

Time on job: (Yrs & Mos)

Job Status:

Classification:

Employee Disposition Status:

Medication prescribed? If yes list medications.

Describe injury.

Detail any first-aid or medical treatment administered. (Provide names)

Property Damage:

Photo of damage.

Property Damage:

Photo of damage.

Estimated cost of damage:

Vehicle ID:

Make/Model:

Age:

Equipment ID:

Model:

Age:

Detailed description of incident. (Include environmental conditions at time of incident)

Environmental photo:

Environmental photo:

Immediate (Direct Causes):

Direct cause photo:

Direct cause photo:

Contributing (underlying) Factors:

Contributing factors photo:

Corrective Action (Include detail description of action and person(s) responsible for actions)

What was the potential for severity?

What could have potentially happened?

What is the probability of reoccurrance?