Equipment Damage Report
CS Construction, Inc.
Type of Incident
*
Equipment
Property
Theft
3rd Party Liability
Near Hit
Supervisor Name
*
First & Last Name
Date & Time Incident Occurred
*
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Date & Time Incident Reported
*
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Employee Name
*
First & Last Name
Time Employee Started Work
*
Hour Minutes
AM
PM
AM/PM Option
Witnesses
(If Any)
Job Number
*
Ex: 1346A
Were Photos Taken?
*
Yes
No
Equipment Number
*
Ex: 7-89
Equipment Status
*
Rented
Owned
Work Process Being Performed
*
What Work Was Being Completed?
Did Employee Conduct 360 Prior?
*
Yes
No
Describe The Incident
*
Step-By-Step - Give Details. What Happened & Why?
List All Factors That Caused The Incident
*
Ex: Weather, Distracted Driving, Etc.
List Suggestions To Prevent This From Happening Again
*
Employee Written Statement
*
Describe In Detail What Happened
Repair/Injury Cost Estimate
*
Total Amount (Approximate)
Incident Cause
*
Preventable
Non-Preventable
Image Upload
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Report Completed/Received By Supervisor Name
*
First & Last Name
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