Report Injury/Incident
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Company Name
Date of Incident
Project Name
Project City:
Project State:
Project Country:
Submitter's Name
Submitter's Email
New Hire:
Yes
No
Check which applies to incident:
Behavior
Condition
Incident Type
(Check all that apply):
Injury/Illness
Property Damage
Vehicle
Environmental Release
Other
Employee Classification:
Non-Manual
Electrician
Tower Erector
Ironworker
Laborer
Equipment Operator
Painter
Rigger
Technician
Severity:
First Aid Case
Lost Time
Medical Case
Restricted Duty
Near Miss (no injury)
Fatality
Injury Sustained
(Body Part):
Injury Sustained
(Type, Sprain/Fracture, etc.):
Did employee visit ER, Hospital or Doctor?
Yes
No
First Aid Administered / Repairs Being Made, and by whom?
Yes
No
Administered by?
Was a pre-job safety briefing held before work began?
Yes
No
What Personal Protective Equipment was being used?
Describe the work activity at time of incident:
(What was the assigned task of the crew or person involved in the incident)
Describe the Incident:
(Where was the employee; what was the employee doing; how did the incident occur)
Cause(s) of Incident
What Is Employee's Current Status if Injured?
Describe Below (Returned to Work, Off Work, In Hospital, etc)
Comments
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