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
*
Please use 24-hour time
Project (if any)
Location on the Jobsite
*
E.g. Ground, roof, etc.
Employee Filling Out Report
*
Employees Involved or Witnesses to Accident/Incident/Injury
Employee involved in accident
Full Address of Location Accident/Injury/Incident Occurred
Explain the sequence of events leading up to the accident/injury/incident
*
Were there any injuries?
*
Yes
No
Explain the injury as specifically as possible below.
*
Please be specific. Answer questions, like: What type of injury occurred? What part of the body was injured? What does it feel like (i.e. stabbing pain, aching, 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 the vehicle information of any RETHINK vehicle here.
Include 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
Were there any other (non-Rethink) vehicles involved?
Yes
No
If yes, please provide the vehicle information of any NON-Rethink vehicles here.
Include VIN, year, make, model, and vehicle number.
What (if any) were the damages to the (non-Rethink) vehicle(s)?
Does this vehicle need to be towed?
Yes
No
Maybe
Please upload police report
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