Incident Report Form
Name
First Name
Last Name
Preparer E-Mail
Preparer E-Mail FIELD
example@example.com
Incident Date
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Project / Job Number
Project / Job Name
Location
Project Manager
Project Mgr E-Mail
PM E-Mail FIELD
example@example.com
Superintendent
Superintendent EMail
Super E-Mail FIELD
example@example.com
Foreman
Foreman EMail
Foreman E-Mail FIELD
example@example.com
OCIP Job?
No
Yes
Owner Name
Owner Phone Number
Please enter a valid phone number.
GC Name & Contact
GC Phone Number
Please enter a valid phone number.
Who
What
When
Where
Why
How
Status
Paragraph Summary of Incident
Preventive Measures
Disciplinary Actions Taken
Image or File Upload
Browse Files
Drag and drop files here
Choose a file
Cancel
of
File / Image Upload
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Preparer Signature
Employee Signature
Foreman Signature
Superintendent Signature
PM Signature
Safety Manager Signature
SVP HR / Safety Signature
Below to be completed by SVP / HR / Safety ONLY
Safety Manager Incident Rating (1-5 with 5 Being Most Severe)
Please Select
1 - Theft / Stolen Property
2 - Auto Accident
3 - Injury / Near Miss / First Aid
4 - Injury due to negligence (not wearing PPE)
5 - Fall Protection / Property Damage (Leaks / Damage Using Equip)
To be filled in only by Safety Manager
Incident Category
Please Select
General Liability
Worker's Comp
Auto
To be completed by SVP HR / Risk / Safety
Post Accident Drug Testing Required?
No
Yes
Signature of Person Completing this Section
Submit
Should be Empty: