Accident/Incident Report

Accident/Incident Report
General Information
Date of Event

MonthDayYear
Date
Time

Hour Minutes

AM/PM Option
Company
Which Location?
Jobsite location, quarry location, plant location, etc.
Is this an injury or property related incident? (Check all that apply)
Affiliation of all involved persons (check all that apply):
People Involved

Please add all of the people who were involved, their phone number, and respective affiliation.
People involved:
Was anyone injured?
If yes, please complete the following for all reported injuries:
Please describe the injury or injuries:
Examples: John Smith (laceration to left thumb), Jane Jones (swelling to right wrist), etc.
Event Details
Describe the event in as much detail as possible:
Examples: John Smith stepped off of the curb and twisted his right ankle. John tried to continue work but reported it to his supervisor approximately one hour after the injury occurred. The supervisor observed visible swelling to John's right ankle. -OR- An Amazon delivery vehicle was driving northbound on I-95 when it swerved and struck the temporary barrier along the work site. The Amazon vehicle sustained damage to the front end that rendered the vehicle inoperable. The temporary barrier also sustained damaged and will need to be replaced.
Location of the injury/incident:
Examples: 123 First Street, Philadelphia, PA 00000 -OR- PA Turnpike Mile Marker 33.0 -OR- Describe area to your best ability.
Witness(es) (provide name, phone number, and affiliation):
Were the Police involved?
If yes, which Police Department?
Property Related Information
How was the property affected? (Check all that apply)
Company Equipment/Truck #:
Property involved (please add the owner's name, owner's phone number, and a description of the property and it's damage):
Examples: John Smith (111-111-1111) 2020 Ford F150 (PA Tag: ABC123) broken headlight and dent to front passenger quarter panel. -OR- James D. Morrissey, Inc. Honda suitcase generator was stolen during the overnight hours of 10/23/24-10/24/24.
Additional Details
Employee submitting this report:

First NameLast Name
Email
Add the e-mail address of anyone else who you would like to receive this report. This field is for INTERNAL EMAIL ADDRESSES ONLY. Any external entity wishing to receive a copy of this report must contact the safety department directly.
Additional Email
Add the e-mail address of anyone else who you would like to receive this report. This field is for INTERNAL EMAIL ADDRESSES ONLY. Any external entity wishing to receive a copy of this report must contact the safety department directly.
Please upload all photographs and related documents:

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Accident/Incident Report

General Information

People Involved

Event Details

Property Related Information

Additional Details