• EventLink LLC INCIDENT / ACCIDENT REPORTSubmitted by each involved individual

• This report must be submitted within 24 hours of the documented incident. A separate form must be submitted for each individual that is involved in an incident, or has experienced any bodily injury.  Please take photos and provide support documents, such as police or hospital reports, to help build a case file on these incidents and accidents. These photos and documents can be sent to incidentreports@go2eventlink.com, within the same 24 hour time frame. The report, photos, and support documents will be sent automatically to the Human Resource Manger, Operations Managers, Executive Director of Production Services, Director of Production Services, Company President, and Executive Vice President. They will also be forwarded along to the corresponding Executive Producer staff upon submission. 
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• GENERAL QUESTIONS
• Today"s date*
   -Month -DayYear

  Date
• Date of incident*
   -Month -DayYear

  Date
• Name of site where injury, illness, incident or accident took place. If on a street or in transit, please be as descriptive as you can (ex: mile marker 32 on rt75N or about 400" west of the corner of Pine St and Main St, Tech area on site, track entrance #1, etc.).*
• Time of incident (include am/pm)*
• Street address of site or incident location.*
• City*
• State*
• Zip code*
• Country*
• Is a copy of this report required for the client?
  YesNo
• Name and title of person completing this report*
• Phone number*
• Name of Road Producer responsible for this event or vehicle move. If other than person completing this report.
• Phone number
• Executive Producer*
• Phone number*
• Event name*
• Job number (E20XXX "or" S20XXX)*
• The incident resulted in:*
  Bodily Injury or IllnessProperty, Equipment or Vehicle DamageBodily Injury and Property, Equipment or Vehicle Damage
• The following pages are as follows: Bodily Injury or Illness Information, Medical Facility Information, Equipment or Property Damage Information, Vehicle Damage Information, Police Information, and Witness Information. Please complete the sections that correspond to your above selection about the incident in entirety. As an example, if an employee gets injured, please complete the Bodily Injury or Illness Information, Medical Facility Information (if applicable), and Witness Information. If an employee gets injured in a vehicle, complete the Bodily Injury or Illness Information, Medical Facility Information (if applicable), Vehicle Damage Information, and Witness Information.
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• BODILY INJURY OR ILLNESS INFORMATION
• Complete the following fields if there was an person who became ill or suffered an injury resulting from an incident or vehicle accident. You will need to complete this section if the individual is an employee, participant, or any other person on the event site.
• Name of person injured or who has suffered an illness.
• Phone number
• Street address of site or incident location
• City
• State
• Zip code
• Country
• Gender
  MaleFemale
• Is this individual an employee of EventLink?
  YesNo
• Please describe the injury or illness and its location. Be exact with the location of the injury (cut on the right forearm, burn on the left knee, etc).
• Please describe how the injury or illness occurred. Include all details of the incident (what the person was doing, what the weather was like, what the location was like, etc.) that were factors in causing the injury.
• What outside material was involved in causing the injury (scrap metal, equipment, etc.)?
• Does Human Resources need to call the individual"s emergency contacts?
  YesNo
• Time the employee began work on the day of the injury or illness (include am/pm).
• Time the employee ended work on the day of the injury or illness (include am/pm).
• Did the injury occur as a result of a vehicle accident?
  YesNo
• Did the individual seek medical attention?
  YesNo
• Did the employee return to work that day after seeking medical attention?
  YesNo
• Time the employee returned to work (if applicable and include am/pm)?
• Is the employee going to miss more time from scheduled work because of the injury or illness?
  YesNo
• If yes, please provide details.
• If the employee has any restrictions from a doctor, are there modified duties and tasks available?
  YesNo
• If yes, please provide details.
• Did the individual drive themselves to seek medical attention?
  YesNo
• If no, please provide details.
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• MEDICAL FACILITY INFORMATION
• If the injured person was treated at a hospital, complete the following section.
• Did this individual refuse to go to a medical institution after it was recommended to do so?
  YesNo
• Name of medical facility
• Street address of site or incident location
• City
• State
• Zip code
• Country
• Medical facility phone number
• Name of treating physician
• Please describe the treatment that was administered by the physician.
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• EQUIPMENT OR PROPERTY DAMAGE INFORMATION
• Please complete this section for any incidents that result in any equipment or property damage. Do not complete this section for vehicles.
• Please describe the equipment or property that was damaged. Be specific (wheel stand, trailer graphics, personal property).
• Please describe how the damage happened in detail. Be specific (wind knocked it over, etc.)
• Who owns the equipment or property?
  EventLinkClientOther
• If an employee was involved, was the employee sent for a drug screen?
  YesNo
• If yes, provide the date the employee was sent. If no, provide the reason why the employee did not go for a screening.
• Was a police report filed? If yes, complete the Police Information section of this report.
  YesNo
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• VEHICLE DAMAGE INFORMATION
• Please complete this section for any incidents or accidents that resulted in any vehicle damage. Damage to Company, client, and personal vehicles will all be completed in this section. Include ALL vehicles that are involved in the incident or accident.
• Describe how the vehicle incident or accident occurred with as much detail as possible. Be specific (location, speed, speed limit, traffic conditions, weather conditions, all vehicles and property involved).
• Vehicle one damage
  EventLink VehicleClient or program vehicleOther
• Driver name
• Phone number
• Is this individual an EventLink Employee?
  YesNo
• Year of the vehicle
• Make of the vehicle
• Model of the vehicle
• Color of the vehicle
• VIN of the vehicle
• License plate of the vehicle
• Owner of the vehicle (if different from the driver)
• Include any extra information (insurance, etc.)
• Vehicle two damage
  EventLink VehicleClient or program vehicleOther
• Driver name
• Phone Number
• Is this individual an EventLink employee?
  YesNo
• Year of the vehicle
• Make of the vehicle
• Model of the vehicle
• Color of the vehicle
• VIN of the vehicle
• License plate of the vehicle
• Owner of the vehicle (if different from the driver)
• Include any extra information (insurance, etc.)
• Vehicle three damage
  EventLink VehicleClient or program vehicleOther
• Driver name
• Phone number
• Is this individual an EventLink employee?
  YesNo
• Year of the vehicle
• Make of the vehicle
• Model of the vehicle
• Color of the vehicle
• VIN of the vehicle
• License plate of the vehicle
• Owner of the vehicle (if different from the driver)
• Include any extra information (insurance, etc.)
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• POLICE INFORMATION
• If a police report was filed, provide the requested information below. You will also need to obtain a copy of the police report and submit it to Human Resources and the Operations Manager to add to the claim file.
• Reporting officer"s name
• File or report number
• Reporting officer"s department or precinct
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• WITNESS INFORMATION
• Gather as many witnesses as you can for the Incident Accident Report.
• Witness one name
• Phone number
• Witness description of what occurred.
• Witness two name
• Phone number
• Witness description of what occurred.
• Witness three name
• Phone number
• Witness description of what occurred.
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• PHOTO SUBMISSION
• Upload Image
  Upload a File

  4MB Max File Size Cancelof
• E-mail
• Submit
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