Accident/Injury/Incident Form
Please fill this form out as soon as possible after an accident/injury/incident occurs.
Date
*
-
Month
-
Day
Year
Date
Time of Accident/ Injury/ Incident
*
Hour Minutes
AM
PM
AM/PM Option
Location on the job site ( ground, roof, etc.)
*
Employee Filling out report
*
Employee involved in accident
*
Location of accident (FULL address)
*
Explain Accident Below using as much detail as possible (What Happened? Why did it happen? Specifics- if lifting; How much/ how many? If hit; how? why? all details)
*
Were there any injuries?
*
Yes
No
Explain the injury- what type of injury occured? Ex: Back injury; What does it feel like? stabbing, pain,. cut, etc.)
*
What could have prevented this? A policy? A procedure?
*
What does the employee think they did to contribute or cause this?
*
Who were witnesses to the accident? List All named (FULL NAMES) and attach the witness statements
*
Was there a Vehicle Involved?
*
Yes
No
If Yes, Please provide RETHINK's Vehicle information here: (VIN, YEAR, MAKE, MODEL, and VEHICLE NUMBER)
*
What (if any ) were the damages to the vehicle?
Does this vehicle need to be towed?
Yes
No
Maybe
Was there another vehicle involved?
Yes
No
If Yes, please provide the OTHER vehicle information NAME, VEHICLE YEAR, VIN, MAKE, MODEL)
What (if any ) were the damages to the vehicle?
Does this vehicle need to be towed?
Yes
No
Maybe
Please upload police report
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Please upload photos
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