Synergo LLC
www.teamsynergo.com - 503.746.6646
15995 SW 74th Ave STE 200, Tigard Oregon
97224
INCIDENTREPORT
Date of Incident:
-
Month
-
Day
Year
Date
Time of Incident:
Hour Minutes
AM
PM
AM/PM Option
Name of Site:
Name of Injured Person:
Injured Person's Address:
Injured Person's Phone Number:
Format: (000) 000-0000.
Witness 1
Witness to the Incident
Witness 1 Phone Number
Format: (000) 000-0000.
Witness 2
Witness to the Incident
Witness 2 Phone Number:
Witness to the Incident
Format: (000) 000-0000.
TYPE OF INCIDENT:
Minor Illness
Serious Illness
Minor Injury
Serious Injury
LOCATION OF INCIDENT (CHECK ALL THAT APPLY):
On Element
Facility Related
Loading
Off Element
Not Facility Related
Unloading
Was Participant Hospitalized?
Yes
No
First Aid administered:
If possible, have the injured person describe in their own words what happened:
Injured Person's Signature
Date
-
Month
-
Day
Year
Date
STAFF INCIDENT REPORTING:
An incident report should be completed by the builders involved as soon as possible with the Who, What, Where, When, and Why of the accident. REPORT FACTS, NOT FAULTS! The cause of the incident and the corrective action taken to prevent reoccurrence will be discussed during the Safety meetings.
What Happened? Please describe the circumstances leading to the incident.
Document created by Synergo
15995 SW 74th Ave Suite 200 Tigard, Oregon 97224
www.teamsynergo.com • (503) 746-6646 phone • (503) 746-69446 fax
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INCIDENTREPORT
Please describe the type of injury(s) sustained:
Please indicate on diagram the location(s) of any injury:
Indicate Location of Injury
1
2
3
4
5
6
7
8
9
10
11
12
13
14
Describe the first-aid treatment administered (prior to any hospitalization), including medications given:
I agree with the information and conditions of this accident as described on both sides of this report.
Staff Signature:
Date of Report:
-
Month
-
Day
Year
Date
Please give report to the Supervisor as soon as possible.
OFFICE USE ONLY
Name of Safety Committee Chair:
Date Reviewed:
-
Month
-
Day
Year
Date
Reviewed by:
Next Safety Meeting Date:
-
Month
-
Day
Year
Date
What Follow-up occurred:
Document created by Synergo
15995 SW 74th Ave Suite 200 Tigard, Oregon 97224
www.teamsynergo.com • (503) 746-6646 phone • (503) 746-69446 fax
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