Employee Accident/Near Miss/Work Stoppage

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
Name of person filing this report:

First NameLast Name
Supervisor

Other
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
Describe the injury
What condition contributed to incident?

Other
What caused or influenced substandard conditions?

Other
What action contributed to the incident?

Other
Probable Recurrence
Loss Severity Potential
What task/duties need to be done before work can safely be resumed:
Signatures
Employee Signature
Should be Empty: