WCHA WZS Reporting Form
Date of Incident
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Email Address of Individual Filling Out This Form
example@example.com
Name of County
Location
Please Select
Interstate
US Highway
STH
CTH
Local-Rural
Local-Urban
Location
County; State; Local-Rural; Local-Urban
Workzone Type?
Please Select
Closed-Detour
Mobile Operation
RT Lane Closure
LT Lane Closure
Single Flagger
Multiple Flagger
Flagger & Pilot Cars
Shoulder Closure
Off Roadway
Mowing
Plowing
Off Roadway Other
Workzone Type
Closed - Detour; Mobile Operation; Lane Closure; Flagger 1/2; Shoulder Closure; Off Roadway; Plowing; Other
Workzone Field Guide Layout #
Type of Occurrence
Please Select
Accident (Injury)
Incident (Property)
Near-Miss (WC/None)
Type of Occurance
Accident - Injury/Fatality; Incident - Property; Near-Miss
Time of Incident
Flaggers Utilized?
Work Zone Signage Layout Present
Layout # from WZS Guidebook or Other
Citation
Accident Y?; # of injury/fatal
I2 / F1
Incident Y? - County Property Damage $
Near-Miss Y? WC related
Yes / No
Description of Incident
County; State; Local-Rural; Local-Urban
Accident - Incident- Near / Miss Information
Accident involving Injury(ies)?
Accident involving Fatality(ies)?
County Employee Injury?
County Employee Injury resulting in Worker's Compensation?
County Employee Fatality?
County Property Damage?
County Vehicle Damage?
Private Vehicle Damage?
Employee Left Work for Day?
Employee at Work but Re-assigned?
Other
Estimated $ Value of Damage / Loss to County?
$X,XXX.XX
Traffic Control Items (Check All That Apply)
PORTABLE MESSAGE SIGNS
ADVANCED WARNING SIGNAGE (ROLL-UPS)
ARROW BOARDS
TEMPORARY BARRIERS
RUMBLE STRIPS
FLAGGERS
TEMPORARY SIGNALS
SPEED REDUCTION
PILOT VEHICLES
DRUMS
42-Inch CONES
Other
Traffic Control Items
If an accident, MV Report #?
MV Report # or N/A
Description of What Occured
If citations issued please describe.
Submit
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