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
Will the TOTAL ESTIMATED Cost to KPost for this Incident be $5,000 or Greater?
*
No
Yes
Owner Name
Owner Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
GC Name & Contact
GC Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
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
All employees involved in a qualifying accident (vehicle collision, fall from height, or injury requiring medical attention) must submit to post-accident drug/alcohol testing per company policy.
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 (Major 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: