Injury/Near Miss/Safety Incident Report
Date
-
Month
-
Day
Year
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Time
Hour Minutes
AM
PM
AM/PM Option
Submitter Name
*
First Name
Last Name
Name of Other Individual Involved (if any)
First Name
Last Name
Home Branch Location
*
Please Select
MW- Norwalk
Baldwin Park
Palmdale
Customer Name
Jobsite Address
Location of accident
*
Address or nearest cross streets. Include direction of travel. Ex: N/B on Maple Ave approaching Del Amo Blvd.
Type of Incident
*
Injury/Illness
Near Miss
Safety Incident
Was Manager contacted?
*
Yes
No
Was Police Contacted/emergency services?
*
Yes
No
Name of Emergency Services Department Contacted
*
Weather and Road Conditions (Check all that apply)
*
Sunny
Cloudy
Rainy
Windy
Foggy
Snow
Ice
Wet
Dry
Paved
Unpaved
Gravel
Soft Dirt
Uneven Pavement
Describe the incident or injury with as much detail as possible. What happened leading to the incident and what happened after.
*
Include details to who, when, what, where, how.
Were there other witnesses present?
*
Yes
No
Witness 1 (other than drivers)
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Witness 2 (other than drivers)
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Upload all photos or video of the incident and any related items that may help tell the story.
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