Skip to content
TELL US WHAT YOU WANT AND WE WILL BUILD IT WITH A BEST PRICE GUARANTEE!
Welcome
Login
Menu
Close
Welcome
Login
Incident and Injury Report
Incident and Injury Report
GENERAL INFORMATION
Report By
Report Date
*
Accident Date
*
Time of Incident
*
12
1
2
3
4
5
6
7
8
9
10
11
:
00
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
AM
PM
Time Zone
*
Enter
Eastern
Central
Mountain
Pacific
Superintendent
*
Foreman
*
Project Manager
*
Project Number
*
Location
*
Incident
State
*
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
County Parish
*
Division
Your Divisions Will Be Added
Reported To Authorities
*
Yes
No
If Yes – To What Agency?
*
Company Involvement
*
Caused By
Contributed
Involved In
Witnessed
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 Applicable
Head
Eyes
Neck
Trunk
Upper Extremities
*
Not Applicable
Shoulder
Arm
Wrist
Hand
Finger
Lower Extremities
*
Not Applicable
Knee
Ankle
Foot
Toe
Nature of Injury or Illness
*
Not Applicable
Cut, Laceration or Puncture
Bruise or Contusion
Chemical Burn
Thermal Burn
General Soreness or Pain
Other
EMPLOYEE INFORMATION
Do you need to enter Employee Information?
*
No
Yes
Full Name
Telephone Number
*
Marital Status
N/A
Married
Divorced
Single
Other
Number of Children
Occupation
*
Race
N/A
White
Black
Indian
Asian
Other
Age
*
Time Present Job
*
N/A
0-2 Mos
3-6 Mos
6-12 Mos
1-3 Yrs
3-5 Yrs
5-7 Yrs
7-9 Yrs
9-15 Yrs
15+ Yrs
Time This Industry
*
N/A
0-2 Mos
3-6 Mos
6-12 Mos
1-3 Yrs
3-5 Yrs
5-7 Yrs
7-9 Yrs
9-15 Yrs
15+ Yrs
Time Present Occupation
*
N/A
0-2 Mos
3-6 Mos
6-12 Mos
1-3 Yrs
3-5 Yrs
5-7 Yrs
7-9 Yrs
9-15 Yrs
15+ Yrs
List Witnesses and Contact Information
*
N/A
MEDICAL INFORMATION
Do you need to enter Medical Information?
*
No
Yes
Treatment Facility
*
N/A
Hospital
Emergency Room
Occupational 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.
