CONTRACTOR INCIDENT REPORT FORM

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NOTE: To be completed by Project Manager or Facilities Manager.

Completed form to be returned to Compliance Director within 24 hours of Incident

.

Date of Report:

Injured Party:

Employer:

Site: Site Location:

Report Prepared By: Title:

Signature: _______________________________

1. ACCIDENT/INCIDENT CATEGORY (check all that apply – Double click and select “CHECKED”)

Injury Illness Near Miss Property Damage Fire Chemical Exposure

On-site Equipment Motor Vehicle Electrical Mechanical Spill

Other (Specify: )

2. DATE AND TIME OF ACCIDENT/INCIDENT: (AM/PM)

In a narrative report of the Accident/Incident, please identify the actions leading to or contributing to the

accident/incident and the actions following the accident/incident.

3. WITNESS TO ACCIDENT/INCIDENT:

Name: Company:

Address: Phone No.:

Name: Company:

Address: Phone No.:

4. INJURED - ILL:

Name: Address: Age:

Length of Service: Time on Present Job: Time/Classification:

5. SEVERITY OF INJURY OR ILLNESS:

Disabling Non-disabling Fatality Medical Treatment First Aid Only

6. ESTIMATED NUMBER OF DAYS AWAY FROM JOB:

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7. NATURE OF INJURY OR ILLNESS:

8. CLASSIFICATION OF INJURY (Check all that apply - Double click and select “CHECKED”):

Abrasions Dislocations Punctures Bites Faint/Dizziness Radiation Burns

Blisters Fractures Respiratory Allergy Bruises Frostbite Sprains

Chemical Burns Heat Burns Toxic Resp. Exposure Cold Exposure

Heat Exhaustion Toxic Ingestion Concussion Heat Stroke Dermal Allergy Lacerations

 Part of Body Affected:

 Degree of Disability:

 Date Medical Care was received:

 Where Medical Care was received:

 Address (if off-site):

9. PROPERTY DAMAGE:

Description of Damage:

Cost of Damage: $

10. ACCIDENT/INCIDENT ANALYSIS: Causative agent most directly related to accident/incident

(Object, substance, material, machinery, equipment, conditions)

 Was weather a factor?

 Unsafe mechanical/physical/environmental condition at time of accident/incident (Be specific):

 Personal factors (Attitude, knowledge or skill, reaction time, fatigue, hobbies):

11. ON-SITE ACCIDENTS/INCIDENTS:

Level of personal protection equipment required in Site Safety Plan (if applicable):

 Modifications:

 Was injured using required equipment?

 If not, how did actual equipment use differ from plan?

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12. ACTION TAKEN TO PREVENT RECURRENCE:

(Be specific. What has or will be done? When will it

be done? Who is the responsible party to insure that the correction is made?)

13. ACCIDENT/INCIDENT REPORT REVIEWED BY:

Name Printed: Signature __________________________

14. OTHERS PARTICIPATING IN INVESTIGATION:

Signature __________________________ Title