FIELD INCIDENT REPORTING FORM

FIELD INCIDENT REPORT FORM
Date of Incident

MonthDayYear
Date
Time of Incident
Incident Location
Employees Involved
Type of Incident

Job Related IllnessJob Related InjuryProperty DamageOther
Cause of Incident

Unsafe ActUnsafe Condition of AreaUnsafe Condition of EquipmentUnsafe Use of EquipmentSafety Policy ViolationOther
Describe the incident in detail
Were safety procedures violated. Describe.
Job Name
Job Number
Job Project Manager
Jobsite Address
Witness Name
Witness Phone
Incident site inspection. Why was an unsafe act committed or why was the unsafe condition present.
Incident Photos
Recommendationssteps to take to prevent a similar incident
Reporters Name
Date Reported

MonthDayYear
Date
Additional Comments
Safety Manager - Ryan Grefsheim - 763.458.3137 - ryang@aaimn.com

Safety Specialist - Nina Hennen 763.200.2616 - kristinah@aaimn.com

Panel Shop Superintendent Jamey Johnson - 763.286.7117 panelshop@aaimn.com

Carpenter Superintendent - Craig Serfas - 763.286.8223 - craig.s@aaimn.com

Flooring Superintendent Craig Gunderson - 763.286.8484 gundy@aaimn.com

Tile/Concrete Superintendent - Rodney Baldwin - 763.286.8213 -rodney@aaimn.com
Should be Empty: