Initial Report
Follow-up Report
Final Report
Date
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Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Contractor Incident Report System (CIRS)
1. Contract Information
Incident Information
Prime Contractor:
Cage Code:
Contract Number:
Installation of Incident:
Task Order #:
Contracting Activity/ROICC Office:
Contractor Contact Information
Name (Last, First):
First Name
Last Name
Phone #:
Format: (000) 000-0000.
Email Address:
example@example.com
Date Notified:
2. Incident Type
(Please Check/Bold All That Apply)
Assault/Violent Act
Extreme Environmental Exposure
Man over the side (No water entry)
Diving
Falls, slip, trip, or bodily exertion
Man Overboard Water Entry
Electrical Shock/Burns
Fires All Types
Material Handling Equipment
Equipment Installation/Repair
Hazardous Material (any type)
Ordnance-Related (Explosive)
Explosion, Non-Ordnance
Industrial
Vehicle (Government or Private)
Industrial Incident Additional Information
(Please Check/Bold All That Apply)
Confined Space
Hand and Power Tools
Work Platforms and Scaffolding
Demolition/Renovation
Rigging
Underground Construction, Shafts, and Caissons
Trenching/Entrapment
Cranes and Hoisting Equipment
Concrete, Masonry, Steel Erection and Residential Construction
Traffic Control
Floating Plant and Marine Activities
Tree Maintenance and Removal
Welding and Cutting
Pressurized Equipment and System
Airfield and Aircraft Operations
Control of Hazardous Energy
Fall Protection
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3. General Information
Incident Information
Date of Accident:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Time of Accident:
Hour Minutes
AM
PM
AM/PM Option
Describe the accident in detail in your words: (Use the back of page if you need additional space)
Exact Location of Accident:
Were Hazardous Material(s) Involved
Yes
No
If Yes, Explain What Hazardous Materials Were Involved and Why:
Who Provided Clean-up?
Onsite
Base
Public
Activity of the injured person at the time of incident:
Personal Protective Equipment: (Check/Bold Response)
Available and used
Available and not used
Not Required
Not related to Mishap
Wrong PPE for job
List PPE Used:
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4. Fully Explain What Allowed or Caused the Incident:
Direct Cause:
Indirect Cause:
Additional Action Taken: (Please Include a Begin Date and Est. End Date in Description)
Additional Action Taken: (Please Include a Begin Date and Est. End Date in Description) (Use the back of page if you need additional space)
5. Contributing Factors:
Was Visibility Restricted?
Yes
No
Distance Visibility was restricted:
Unit of Measure (Check/Bold):
Feet
Yards
Meters
Miles
Nautical Miles
Visibility Restricted By: (Check/Bold all that apply)
Fog
Smoke
Rain
Sleet
Snow
Mist
Dust
Sandstorm
Unknown Object
Other
Lighting Conditions at Site of Mishap: (Please Check)
Adequate
Inadequate
Unknown
Was Noise Level a Factor: (Please Check)
Yes
No
Unknown
Was Carbon Monoxide (CO) a Factor: (Please Check)
Yes
No
If Yes CO Alarm Manufacturer:
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5. Contributing Factors: Continued
Incident Information
Other Contributing Factors:
6. Attached Documents
Rows
Attached Documents/Files Name/Description:
Date Added:
Uploaded By:
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Contractor Incident Report System (CIRS)
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1. Injured Data
Age:
Gender:
Male
Female
Prime Contractor Company Name:
Subcontractor Company Name:
2. General Information
Drug or Alcohol Involved: (Check/Bold all that apply)
None
Unknown
Alcohol
Drugs
Alcohol and Drugs
Who Provided First Aid?
Onsite
Base
Public
Was Ergonomics a Factor: (Check/Bold)
Yes
No
Type of Ergonomic Injury: (Check/Bold All That Apply)
Lifting
Positioning
Bending
Equipment Placement Office
Equipment Placement Industrial
Repetitive Motion
Impact Strain
3. Injury Illness/Fatality Information
Severity of Injury/Illness: (Check/Bold)
Fatality
Lost Workday Case Involving Days Away From Work
Temporary Disability
Recordable Workday Case Involving Restricted Duty
Permanent Total Disability
Other Recordable Case
Recordable First Aid Case
Permanent Partial Disability
Non-Recordable Case
No Injury
Where There Days Lost: (Check/Bold)
Yes
No
Where There Days Hospitalized: (Check/Bold)
Yes
No
Where There Days Restricted Duty: (Check/Bold)
Yes
No
Part of Body Affected:
Nature of Injury or Illness:
Event or Exposure:
Source of Injury or Illness:
General Location Description:
Injury Activity Code:
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4. License
Are Appropriate License and Certification/Medical Current:
Yes
No
Describe or Explain:
Rows
Attach Image of License or Certification Name/Description:
Date Added:
Uploaded By:
1
2
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5. Training
Was all the contract-required training provided to the employee:
Yes
No
Explain:
6. Attached Documents
Rows
Attached Documents Name/Description:
Date Added:
Uploaded By:
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Contractor Incident Report System (CIRS)
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1. Involved Person Data
(if applicable) Property Damage
Age:
Gender:
Male
Female
Contractor:
Contractor:
2. Attached Documents
Rows
Attached Documents Name/Description:
Date Added:
Uploaded By:
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3. Property Damaged
Was Anyone Injured:
Yes
No
Was A Government Motor Vehicle Involved:
Yes
No
3. Property Damaged
Rows
Property Type
Property ID #
Detailed Description
Property Owned By
Estimated Cost USD
Lost Use Days
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Should be Empty: