Incident Initial Report Form
Employee Filling Out This Report
First Name
Last Name
Project (if any)
Location on the Jobsite
Example: Ground, roof, etc.
Date
-
Month
-
Day
Year
Date
Please use 24-hour time
Employee(s) involved or Witness(es) to Accident/Incident/Injury
Full Address of Location Where Accident/Injury/Incident Occurred
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Explain the sequence of events leading up to the accident/incident/injury.
Were there any injuries?
Yes
No
Explain the injury as specifically as possible.
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.)?
Was there a vehicle involved?
Yes
No
If yes, please provide the vehicle information of any RETHINK vehicle here.
What (if any) were the damages to the vehicle?
Does this vehicle need to towed?
Yes
No
Were there any other (non-Rethink) vehicles involved?
Yes
No
If yes, please provide the vehicle information of any NON-Rethink vehicles here.
What (if any) were the damages to the (non-Rethink) vehicle(s)?
Does any other (non-Rethink) vehicle need to be towed?
Yes
No
Please upload any police reports below.
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