Injury Incident Report Form v2 Company * H.J. Martin and SonMavid ConstructionBIGIISP & M EMPLOYEE'S PERSONAL INFORMATION Name * Phone Number * JOB/PROJECT INFORMATION Job/Project Name * Job/Project # * INCIDENT INFORMATION Incident Date * Incident Time * 121234567891011 : 0030 AMPM Date Incident Reported * Time Incident Reported * 121234567891011 : 0030 AMPM Incident Location * Type of Incident * Please choose...OSHA Incident (Non-injury)Job Incident (Non-injury; Sexual Harassment, Racial Slurs, Evacuation etc.)Property Damage (Non-injury) – (Damage to building, damage to equipment, Hazmat, Environmental)Bodily Injury on or off the job siteMotor Vehicle Accident (with or without injury) OSHA Incident Type if OSHA incident: * What was the employee/subcontractor doing just before the incident occurred? * Describe the incident in your own words (who, what, when, where, why): * Specific area of incident: * Did work stop or shut down because of the incident? * Yes No N/A Explain (how long, etc): * When was the crew able to return to work? * Job Incident (non-OSHA) Type of Incident: * What was the employee/subcontractor doing just before the incident occurred? * Describe the incident in your own words (who, what, when, where, why): * Specific area of incident: * Property Damage (Non-injury) What was the employee/subcontractor doing just before the incident occurred? * Property damage to building or equipment? * Building Equipment Who caused the damage? * Describe the incident in your own words (who, what, when, where, why): * Specific area of incident: * Did work stop or shut down because of the incident? * Yes No N/A Explain (how long, etc): * When was the crew able to return to work? * Bodily Injury on or off the job site What was the employee/subcontractor doing just before the incident occurred? * Describe the incident in your own words (who, what, when, where, why) * Did the employee or subcontractor seek medical treatment? * Yes No N/A What is/was the outcome of medical treatment? * Did work stop or shut down because of the incident? * Yes No N/A Explain (how long, etc): * When was the crew able to return to work? * Motor Vehicle Accident Name of street/road/highway * Direction of travel * Nearest intersection or address * How was the weather? (dry, wet, raining, snowing, etc) * How was visibility? * Were there any distractions? * Did you have proper lookout? Anything obstructing your view? * Was there anything obstructing the claimant's view? * Any nearby cameras from businesses or houses? (*especially if accident is in a parking lot) * Controlled or uncontrolled intersection? * Traffic lights? Stop sign? Etc. * How many lanes of traffic are there in each direction? Dedicated turn lanes? Turn arrows? * Did you have passengers? * Yes No N/A Did the claimant have passengers? * Yes No N/A Did you take evasive action? (honk, brake, swerve, etc) * Yes No N/A If evasive action was taken, what did you do * Describe the accident in your own words (be specific in describing the roadway/intersection): * Was the ambulance called? * Yes No N/A Were the police called? * Yes No N/A Police report #: * Anyone in your vehicle injured? * Yes No N/A What was nature of the injury and names, addresses and phone numbers of each individual injured * Anyone in the claimant's vehicle injured? * Yes No N/A What was nature of the injury and names, addresses and phone numbers of each individual injured in the claimant's vechicle. * Claimant's name, #, address, insurance info (take photo of their license if they let you) * DETAILS OF WITNESS(ES) Use the Add/Remove buttons to add additional witnesses or remove entered ones. Name Contact Phone Number plus1 Add minus1 Remove PHOTOS Please upload any photos relevant to the incident Drop a file here or click to upload Choose File Maximum file size: 16.78MB REVIEW APPROVAL Employee Name * Supervisor Name * Employee Signature * signature keyboard Clear Date * Captcha Submit If you are human, leave this field blank. Δ
