Template Information
Category: general
Template Questions
- Date of Incident:
- Classification:
- Submitted to Safety Date
- Location Name (Branch):
- Location Address:
- City:
- Employer
- Zip Code:
- Location, if different from mailing address (Jobsite Address):
- Name:
- Time in Trade:
- Home Address:
- Responsibility:
- Phone:
- Date of Birth:
- Trade and Classification:
- Project Manager / Superintendent:
- Where Did Incident Occur? (Number & Street, City)
- Incident Information:
- County:
- Job Number:
- What was person doing when accident occurred? ( Be specific, identify tools, equipment, or material employee was using)
- How did the incident occur? (Describe fully the events that led up to the accident. Tell what happened and how it happened.)
- Describe in full damages or consequences of the incident:
- Time of Day:
- Date Employer Notified:
- Who Was Notified? (Name)
- Names and Classifications of Witnesses:
- Check one or more causes that contributed to incident
- Indicate primary incident cause, and explain reason selected:
- Check one or more actions that will prevent a recurrence
- Indicate primary corrective action, and explain reason selected:
- What corrective action is required?
- Completion date for corrective action:
- Person in charge of corrective action:
- Prepared By:
- Reviewed By:
- #1
- #2
- #3
- #4
- #5