Employee Accident/Near Miss/Work Stoppage

Employee Accident - Near Miss - Work Stoppage Reporting
Reporting Date*

MonthDayYear
Date
I would like to file the following type of report*

AccidentNear missWork Stoppage
Name of person filing this report:*

First NameLast Name
Supervisor*

Chris PettisCody ZimmermanEric OdonelJoe PerezJosh DiGulioKris GardnerMichael KovalPaul SchaiderSean SesherZach McCoyOther
Chris Pettis Projects
Cody Zimmerman Projects
Eric O' Donel Projects
Joe Perez Projects
Josh DiGulio Projects
Kris Gardner Projects
Michael Koval Projects
Paul Schaider Projects
Sean Sesher Projects
Zach McCoy Projects
Other Project (jobs that do not appear in the drop down menu above)
Date of the Incident

MonthDayYear
Date
Time of the Incident

:HourMinutesAM/PM Option
Select the employees that were involved in the incident:*
Other Employees on-site
Other people (non-employees) that were involved in the incident
General Contractor/Customer*
Employee's Description of the incident
Job Task at the time of the incident
Equipment that was involved in the incident
Tools that were involved in the incident
Was there an injury

YesNo
Describe the injury
What condition contributed to incident?

Not ApplicableArc Flash hazardDefective EquipmentDefective ToolsEquipment FailureHazardous Site ConditionsImproper fall protectionImproper guards or barriersImproper HousekeepingImproper IlluminationImproper PPEImproper shoringImproper VentilationShock hazardTight ClearanceOther
What caused or influenced substandard conditions?

Not ApplicableAbuse or MisuseInadequate CapacityInadequate EquipmentInadequate MaintenanceInadequate SupervisionInadequate ToolsLack of MotivationLack of PlanningLack of TrainingLack of SkillNegligenceWear and TearOther
What action contributed to the incident?

Not ApplicableFailure to SecureUnder Influence Drugs/AlcoholFailure to Warn/SignalNullified Safety/Control DevicesUsing Defective EquipmentUsing "Tagged-out" tools/equipmentHorseplayOperating at Improper SpeedUsing equipment improperlyImproper liftingRushing/Acting in HasteImproper LoadingUnauthorized ActionsUsing Wrong Tool/EquipmentImproper TechniqueImproper positioningOther
Probable Recurrence

FrequentOccasionalRare
Loss Severity Potential

MajorSeriousMinor
What task/duties need to be done before work can safely be resumed:
Signatures
Employee Signature*

Clear
Should be Empty:

Employee Accident - Near Miss - Work Stoppage Reporting

Signatures