Employee Incident Form

"*" indicates required fields

Check one:

Injury

Incident (Environment)

Both injury and incident

Property Damage - Company Vehicle / Equipment

Close call / near miss

Job Number

Job Name

Contact Information

To be completed by Site Lead

Name*

Job Title*

Division*

Reports to:*

Project Manager

Place / Location/ Address of Incident*

Incident Date*

MM slash DD slash YYYY

Time of Incident*

Hours

Minutes

AM/PM

Date of First Knowledge*

MM slash DD slash YYYY

Date of Report*

MM slash DD slash YYYY

Subcontractor involved?

Yes

Subcontractor Name*

Subcontractor Phone*

Subcontractor email

Injured Party

To be completed by Site Lead

Was there an injury?*

Yes

Injured Party or Driver Name*

Injured Party or Driver Phone Number*

Injury Description*

Has party been involved in other incidents or violations?*

Yes

Please List

Property Damage

To be completed by Site Lead

Was there any property damage?*

Yes

List property / material damage*

Truck / Equipment Number*

Nature of damage*

Object / substance inflicting damage

Approximate cost

Was a Vehicle Involved?*

Yes

Vehicle Incident Diagram Upload

Drop files here or

Accepted file types: jpg, jpeg, gif, png, tif, pdf, mp4, heic, mov, wmv, Max. file size: 50 MB.

The Incident

To be completed by Site Lead

Casual analysis type:

(to be determined by Incident Investigation program manager)

Root cause analysis

Apparent cause

Briefly describe what happened (description of occurrence)*

Investigate scene of incident or conditions. Describe who was involved, when and where the incident happened, what happened, and how. Attach photos of available.

Drop files here or

Max. file size: 50 MB.

Why did it happen? (description of cause)*

What caused the illness, injury, or incident?

What did you do in response? What were the results?

List actions taken and results. (Do not enter corrective actions. See Section 7.)

What should be done to prevent a recurrence? Brief final evaluation and lesson learned.

Use descriptive constructive statements (such as "worker should wear safety glasses"; "worker needs training in lifting techniques"; "a ladder should have been used"). Primary focus should be on engineering controls, where possible.

Employee Statement / Description of Incident

Upload a File Instead

Employee Statement*

Please type the statement in the box or upload a file below

Employee Statement File*

Accepted file types: jpg, jpeg, gif, png, tif, pdf, heic, doc, Max. file size: 50 MB.

Do you have additional witness statements?*

Yes

Additional Statement

Upload a File Instead

Witness Statement

Please type the statement in the box or upload a file below

Employee Statement File*

Accepted file types: jpg, jpeg, gif, png, tif, pdf, heic, doc, Max. file size: 50 MB.

Do you have additional witness statements?*

Yes

Additional Statement

Upload a File Instead

Witness Statement

Please type the statement in the box or upload a file below

File

Max. file size: 50 MB.

Do you have additional witness statements?*

Yes

Additional Statement

Upload a File Instead

Witness Statement

Please type the statement in the box or upload a file below

File

Max. file size: 50 MB.

Do you have additional witness statements?*

Yes

Additional Statement

Upload a File Instead

Witness Statement

Please type the statement in the box or upload a file below

File

Max. file size: 50 MB.

Corrective Actions Tracking System Items

To be completed by Operations Management EHS Team

Action(s) that have or will be taken to prevent a recurrence.

By whom

Target completion date

Actual Completion date

Work Planning and Control (WPC) Authorization Review

To be completed by EHS

Is there a JHA or Work Order that authorized the task being performed when the injury or Incident Occured?

If yes, review the document(s), answer the following questions, and attach a copy to this report.

Yes

Was person involved in incident in full compliance with company policy requirements?

Yes

If not, please explain:

Were hazards sufficiently identified?

Yes

If not, please explain:

Were identified controls adequate?

Yes

If not, please explain:*

Were the identified controls implemented?

Yes

If not, please explain:

Additional Comments

To be completed by EHS and/or Operations Management as needed

Additional Relevant Files

Drop files here or

Max. file size: 50 MB.

Authorizing Signatures

Instructions:

For first aid cases, incidents involving less than $2,000 in damage, or other than a near miss, complete a, b, c, d

For OSHA recordable cases, incidents involving more than $2,000 in damage, or near miss incident: complete a, b, c, d, e

a. Individual Completing Report*

Typed Name*

Date*

MM slash DD slash YYYY

b. Reviewed by Project Manager

Typed Name

Date

MM slash DD slash YYYY

c. Investigation reviewed by Division Director / ManagerReviewed by Project Manager

Typed Name

Date

MM slash DD slash YYYY

d. Investigation reviewed and approved by Director of Safety (signature obtained by Incident Investigation program manager)

Typed Name

Date

MM slash DD slash YYYY

e. Investigation reviewed by either the Division Vice President, Business Development VP or Company President

Typed Name

Date

MM slash DD slash YYYY