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Incident Report Form

INCIDENT / ACCIDENT REPORT FORM

4. Reporting Supervisor Phone Number

6. Date of Incident: *This question is required. This question requires a valid date format of MM/DD/YYYY.

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8. What date are you filling out this report? This question requires a valid date format of MM/DD/YYYY.

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9. Injured worker street address and cell number: *This question is required.

Injured Full Name

Current Street Address

Apt # (if None.. put N/A)

City

State

Zip Code

Cell Phone #

10. Please list the witnesses: If no witnesses please write "none" in the spaces to continue.
*This question is required.

	Witness 1
	Witness 2

11. What treatment did the injured receive? (Select All That Apply) *This question is required.

None
1st Aid
Urgent Care - Which one? Please enter an 'other' value for this selection. * This question is required.
Emergency Room - Which One? Please enter an 'other' value for this selection. * This question is required.

12. Who will be the point of contact that is with the injured worker? (If none write "none") *This question is required.

13. Point of Contact Phone Number:

14. Did the employee return to the jobsite and continue working on the same day? *This question is required.

15. Describe Incident/Injury:
Please include floor/area, description of the injury (part of the body, type of injury), and a step by step explanation of how the incident occurred. *This question is required.

16. Was the worker wearing Personal Protection Equipment? Select all that he/she was wearing: *This question is required.

17. What were the weather conditions on this day? *This question is required.

18. Was the incident caused by Faulty Equipment, or a Vehicle? *This question is required.

You indicated the injury was caused by Faulty Equipment or a Vehicle, Please provide details of the equipment *This question is required.

19. Did the worker have a previous injury and/or underlying illness that you know of? *This question is required.

You indicated the worker had a previous injury/underlying illness. Please describe in detail.

20. **Our company policy states a Breathalyzer test is required for all injured workers as of May 2022.
Please indicate the result of the test: *This question is required. This question requires a valid number format.

21. Did you take pictures of all of the following: *This question is required.

The injury BEFORE and AFTER bandaging
The BAC Reading
The workers boots, helmet, glasses, or gloves anything that was involved. ESPECIALLY if an object pierces through it
Object that caused injury.. knife, tools, a beam, nail, a rebar
The precise area where the injury happened
Discharge paperwork if there is an urgent care or hospital visit

22. Please upload any pictures you have on your device at this time. Otherwise, email photos.

File: {{filename}} delete

23. Is the Injured Employee with you right now? If so, please have them sign *This question is required.

Worker to confirm all answers are true and correct? *This question is required.

Clear

Signature of