Incident and Injury Report GENERAL INFORMATION Report By Report Date * Time Zone * EnterEasternCentralMountainPacific Accident Date * Time of Incident * 121234567891011 : 000102030405060708091011121314151617181920212223242526272829303132333435363738394041424344454647484950515253545556575859 AMPM Superintendent * Foreman * Project Manager * Project Number * Location * Incident State * Please Choose OneAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming County Parish * Division Your Divisions Will Be Added Reported To Authorities * Yes No If Yes – To What Agency? * Company Involvement * Caused ByContributedInvolved InWitnessed CLASSIFICATION OF INCIDENT Check all that apply Treatment * N/A On-Site Off-Site Injury * Yes No Illness * Yes No Spill Release * Yes No Fire * Yes No Security Threat * Yes No Property Damage * Yes No Work Interruption * Yes No Describe the Incident in Detail * N/A Attachments Drop a file here or click to upload Choose File Maximum file size: 516MB Documents, pictures, drawings, etc. INJURY INFORMATION Do you need to enter Injury Information? * No Yes Upper Body * Not ApplicableHeadEyesNeckTrunk Upper Extremities * Not ApplicableShoulderArmWristHandFinger Lower Extremities * Not ApplicableKneeAnkleFootToe Nature of Injury or Illness * Not ApplicableCut, Laceration or PunctureBruise or ContusionChemical BurnThermal BurnGeneral Soreness or PainOther EMPLOYEE INFORMATION Do you need to enter Employee Information? * No Yes Full Name Telephone Number * Marital Status N/A MarriedDivorcedSingleOther Number of Children Occupation * Race N/AWhiteBlackIndianAsianOther Age * Time Present Job * N/A0-2 Mos3-6 Mos6-12 Mos1-3 Yrs3-5 Yrs5-7 Yrs7-9 Yrs9-15 Yrs15+ Yrs Time This Industry * N/A0-2 Mos3-6 Mos6-12 Mos1-3 Yrs3-5 Yrs5-7 Yrs7-9 Yrs9-15 Yrs15+ Yrs Time Present Occupation * N/A0-2 Mos3-6 Mos6-12 Mos1-3 Yrs3-5 Yrs5-7 Yrs7-9 Yrs9-15 Yrs15+ Yrs List Witnesses and Contact Information * N/A MEDICAL INFORMATION Do you need to enter Medical Information? * No Yes Treatment Facility * N/AHospitalEmergency RoomOccupational Clinic Date of First Treatment * Contact Information * INVESTIGATION Do you need to enter Investigation details? * No Yes Root Cause Analysis * N/A Yes No Type of Analysis * N/A Five Why Fishbone Other Define Other * Analysis Team * Cause(s) * N/A Contributing Factors * N/A CORRECTIVE ACTIONS Do you need to enter Corrective Actions information? * No Yes Actions Already Taken * N/A Describe actions taken immediately upon notice of incident Actions Still To Be Taken * N/A Describe actions that will be taken at a later date Projected Date of Completing Actions * Date of actions that have not been completed but will be completed Person Ensuring Corrective Actions * OFFICE USE ONLY Completed by Safety Management Approved By * Submit If you are human, leave this field blank.
