Attachment B: Incident Notification Summary Template

Incident/Life-Threatening: Complete 15 mins to 1-Hour
Near Miss / Low-Severity: Complete within 2-Hours
Attachment B: Incident Notification Summary Template
INSTRUCTIONS: Project Managers must complete this form for all incidents and near misses and remit to:
➤ Immediate Supervisor of the involved employee(s) and management chain-of-command
➤ CHSM at safety@dawsonohana.com
➤ RHSC assigned to the business line: Safety Committee
➤ HR at hr@dawsonohana.com
➤ Corporate Logistics Manager logistics@dawsonohana.com as applicable.
BOTTOM LINE UP FRONT (BLUF) INCIDENT SUMMARY
1. Incident or Near Miss:
2. Date and Time of Incident/ Near Miss:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Time

Hour Minutes

AM/PM Option
3. 911 or WorkCare Incident Intervention called:
4. Status of Workers Compensation Claim Forms:
5. POC of Supervisor or Individual Tending to Injured, as applicable. Include First and Last Name and Phone number:
6. Date of Injury/Onset of Illness:
7. Injured Employee First and Last Name:
8. Injured Employee Job Title:
9. Injured Employee Entity:
10. Where the Event Occurred:
11. Provide the 5-digit Project ID, if applicable:
12. Project Name, if applicable:
13. Project Entity, if applicable:
14. Business Line, if applicable
15. Service Line, if applicable:
16. Identify Damage to Vehicles, Property, Equipment. Include Owner First and Last Name and Phone Number:
17. First and Last name(s) and title(s) of witness(es):
18. Provide current status of the incident area:
19. Provide in BLUF format what occurred. Describe the series of events and results of any damage or injury.
DAWSON
Proprietary Information
Rev #: 07-2025
Attachment B: Incident Notification Summary Template
AD-006 Incident Reporting & Safety Policy
Should be Empty:

Attachment B: Incident Notification Summary Template

BOTTOM LINE UP FRONT (BLUF) INCIDENT SUMMARY