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Hewitt Emergency Services Incident Form
Complete all fields to submit an incident report
53
Questions
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1
Incident Date
*
This field is required.
-
Date
Month
Day
Year
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2
Incident Time
*
This field is required.
00
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
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23
00
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
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19
20
21
22
23
Hour
00
10
20
30
40
50
00
10
20
30
40
50
Minutes
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3
Incident Severity
*
This field is required.
Please Select
Near Miss
Minor
Moderate
Severe
Please Select
Please Select
Near Miss
Minor
Moderate
Severe
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4
Department / Area
*
This field is required.
Please Select
Maintenance
Office
Field Site
Other
Please Select
Please Select
Maintenance
Office
Field Site
Other
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5
Location / Area
*
This field is required.
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6
Reporting Employee
*
This field is required.
First Name
Last Name
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7
Phone Number for Reporting Employee
Please enter a valid phone number.
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8
Supervisor / Manager
*
This field is required.
First Name
Last Name
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9
Number of Witnesses
Please Select
None
1
2
3
4
5
Please Select
Please Select
None
1
2
3
4
5
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10
Witness 1
*
This field is required.
First Name
Last Name
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11
Phone Number for Witness 1
Please enter a valid phone number.
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12
Witness 2
*
This field is required.
First Name
Last Name
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13
Phone Number for Witness 2
Please enter a valid phone number.
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14
Witness 3
First Name
Last Name
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15
Phone Number for Witness 3
Please enter a valid phone number.
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16
Witness 4
First Name
Last Name
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17
Phone Number for Witness 4
Please enter a valid phone number.
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18
Witness 5
First Name
Last Name
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19
Phone Number for Witness 5
Please enter a valid phone number.
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20
Number of Persons Involved
*
This field is required.
Please Select
1
2
3
4
5
Please Select
Please Select
1
2
3
4
5
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21
Person Involved 1
*
This field is required.
First Name
Last Name
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22
Phone Number for Person Involved 1
Please enter a valid phone number.
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23
Person Involved 1 Injured?
*
This field is required.
Yes
No
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24
Person Involved 1 Medical Attention Needed
*
This field is required.
Yes
No
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25
Person Involved 1 Injury Description
*
This field is required.
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26
Person Involved 2
*
This field is required.
First Name
Last Name
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27
Phone Number for Person Involved 2
Please enter a valid phone number.
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28
Person Involved 2 Injured?
*
This field is required.
Yes
No
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29
Person Involved 2 Medical Attention Needed
*
This field is required.
Yes
No
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30
Person Involved 2 Injury Description
*
This field is required.
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31
Person Involved 3
*
This field is required.
First Name
Last Name
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32
Phone Number for Person Involved 3
Please enter a valid phone number.
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33
Person Involved 3 Injured?
*
This field is required.
Yes
No
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34
Person Involved 3 Medical Attention Needed
*
This field is required.
Yes
No
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35
Person Involved 3 Injury Description
*
This field is required.
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36
Person Involved 4
*
This field is required.
First Name
Last Name
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37
Phone Number for Person Involved 4
Please enter a valid phone number.
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38
Person Involved 4 Injured?
*
This field is required.
Yes
No
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39
Person Involved 4 Medical Attention Needed
*
This field is required.
Yes
No
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40
Person Involved 4 Injury Description
*
This field is required.
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41
Person Involved 5
*
This field is required.
First Name
Last Name
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42
Phone Number for Person Involved 5
Please enter a valid phone number.
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43
Person Involved 5 Injured?
*
This field is required.
Yes
No
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44
Person Involved 5 Medical Attention Needed
*
This field is required.
Yes
No
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45
Person Involved 5 Injury Description
*
This field is required.
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46
Incident Description
*
This field is required.
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47
Incident Summary
*
This field is required.
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48
Photo of Incident Scene
*
This field is required.
Drag and drop files here
Select files to upload
Max. file size
: 10.0MB
Upload Photo
Upload a clear photo of the incident scene or affected area.
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49
Additional Photo Upload
Drag and drop files here
Select files to upload
Max. file size
: 10.0MB
Upload a File
Attach any extra photos related to the incident.
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50
Supporting Document Upload
Drag and drop files here
Select files to upload
Max. file size
: 10.0MB
Upload a File
Attach any related reports or documents.
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51
Additional Contact
First Name
Last Name
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52
Phone Number
Please enter a valid phone number.
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53
Date
-
Date
Year
Month
Day
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