Incident Report Form
If you or another employee of Tri State Restorations, LLC® is injured or in immediate danger please CALL 911. If this is a non-emergency situation, please contact your immediate supervisor 301-251-1841.
Your Name:
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First Name
Last Name
I am reporting on behalf of:
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Myself
Another Employee (Enter Name):
Date of Incident:
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Month
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Day
Year
Date
Location of Incident:
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Include address if possible.
Incident Type:
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Please Select
Car Accident
Weather Related
Fire/Explosion
Jobsite Injury
Violence or Threat
Medical
Harassment
Bomb Threat
Chemical Spill/Leak
Other
If you selected "Other" please enter the incident type below:
Describe the injury or incident including parts of body affected and object/substance that directly caused the injury or illness (i.e.: sustained injury from falling off of a ladder at customer residence.)
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Were there any witnesses?
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No
Yes (Enter Name):
Is there any documentation, either physical or digital, regarding the incident available?Examples of evidence includes: photos, hospital reports, emails, notes or text messages
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Yes
No
What types of evidence or documentation is available?Select as many of the following as applicable.
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Photos
Hospital Report
Email
Text Message
No Evidence Available
Other:
Please attach copies of documented evidence below:
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Please list any reasonable accommodation requests in detail below:
I declare that the information provided in this report is true and correct to the best of my knowledge.Provide Signature Below:
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