Incident Notification
Date
-
Month
-
Day
Year
Date
Status
Open
Closed
Incident Type (do not report Spills and Good Catches here)
Injury
Damage
Fire
Line Strike
Reputation
Near Miss
Harassment
Information Only
Workplace Violence or Threat of Violence
Injured/Involved Person
Type of Injury
None
First Aid
Recordable
Lost Time
Fatality
Other
Is this a vehicle accident?
Yes
No
Case Manager
Address where vehicle accident occured
Photo of Other Driver(s) Insurance Card
Browse Files
Cancel
of
Other Vehicle Details
Part of Body Injured
Number of work days missed due to injury
Must be accompanied by care provider instruction to miss work
Number of work days restricted
Must be accompanied by care provider instruction to restrict work
Pinnacol Claim Number
What Happened/Follow-up Notes
Record what happened and subsequent factors
Care Provider
SSN (last four)
***-**-1234
DOB
MM/DD/YYYY
Home Address
Date of Hire
MM/DD/YYYY
Pay Rate
Shift Start Time
**:** am/pm
Department
Location of Incident
Safety Equipment In Use
Is this a High Potential Incident (HPI)?
Yes
No
Time of Event
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Type of Damage
Foreman Name
First Name
Last Name
Person Reporting
Person Reporting Email
example@example.com
Company/s Involved/ Supervisor Name/ Phone #
Witness/s/ Company/ Phone #
Order of Events
Upload Witness Statements
Browse Files
Name the Files
Cancel
of
Capture/Upload Photo(s)
Browse Files
Name the Photos
Cancel
of
Upload Communications (emails, text, etc)
Browse Files
Name the Photos
Cancel
of
Upload Incident Evidence
Browse Files
Name the Files
Cancel
of
Investigation
Investigation Team
What Happened
Why (save to add rows)
Root Cause(s)
Corrective Action Item(s)
Date Closed
-
Month
-
Day
Year
Date
Submit
Should be Empty: