Initial Injury/Illness Notification Form
This reporting form must be completed as thoroughly as possible with as much information that is available at the time of the incident. Recognizing that some information will not be available immediately, document what you can and take pictures of the scene and damage. Notify Supervisor and Safety Department of incident immediately- Dustin Smith, Safety Manager: 480-352-0300.
INSTRUCTIONS
Nurse365 should be contacted for any injury that is not LIFE, LIMB, OR EYE SIGHT at 1-855-288-9490 (Company Name: Atwell, Location Code: 4020193-04) A separate form must be filled out by each person involved in an incident as well as every witness to the incident. Preserve the scene until instructed otherwise by Dustin Smith or Don Engquist. Answer all the questions to the best of your ability.
Job/ Location
Laurel, MT WWTP
Parker, AZ Tank
Silverton, CO
Other
Your Name
First Name
Last Name
Your Email Address
A copy of this report will be sent to you
Date of Incident
-
Month
-
Day
Year
Date
Time of Incident
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Where did this incident happen?
Incident Type
Injury, Property Damage, Environmental, Reputation, etc...
Responding Safety Professional
First Name
Last Name
Was Law Enforcement or Emergency Responders Called
Yes
No
Name of Responding Agencies
Name/s of Responding Officer/s and or Emergency Responder/s
Number of People Involved
Company the involved person/s work for?
Type of Incident
Non-Work Related
Illness
Near Miss
First Aid
Recordable
Fatality
Persons Involved in the Incident
Phone Number/s of Person/s Involved
Supervisor of Person Injured
First Name
Last Name
Supervisor Phone Number
-
Area Code
Phone Number
What Happened/ Witness Statement
Provide as much detail as possible
Take photo of scene where incident occured
Take photo of damage, injury or evidence
Submit
Should be Empty: