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Construction incident report template

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Accident / Incidnet Report
Information
Report Prepared By
Select date
Phone Number
Contacted Safety Officer
Name of Safety Officer
#1 Project Information
Jobsite Name
Add location
Project Manager
Superintendent
Foreman
Safety Coordinator
#2 Employee / Incident Information
Employee Name
SSN#
DOB
Address
Home Phone Number
Date of Hire
Job Title
End Time
Exact Location Of Incident (Bldg/Leve/Area)
General Task At Time Of Incident (i.e. Moving Strut)
Specific Activity At Time Of Incident (i.e. Bending Over To P/U Strut)
#3 Injury / Illness Information
Date and Time of Incident
Day Of Week
Date Reported to Dome
Reported to Whom at Dome
Type of Injury
Part of Body Injured
Was First Aid Given
By Whom
Was Employee Taken to a Medical Facility Offsite
Select date
Treating Facility
Facility Phone No.
Transported by
Name of Driver
Employee Returned to
Estimated Return Date
Employee's Supervisor
Working on a Crew
Crew Size
#4 Incident Designation (checked by safety professional only)
Name
Designation
#5 Description of the Incident (not to be completed by the injured worker)
Describe in detail the circumstances of the incident (attach diagrams, drawings and/or photos of accident scene). Give chronological sequence of events. If materials and/or equipment were involved, start before the materials/equipment were brought to the incident scene describing who, what, where, when, how:
Attach Photo
Add media
Add media
Add media
Add media
The following is a summary of events
#6 Additional Information
Name of witnesses and others working with injured worker (include statements with report)
Objects, substance, equip. involved in incident (desc/model/serial #)
List PPE worn at time of incident
Safety equipment & training required for job
Does employee normally operate this equipment
Was employee instructed in the safe use of this equipment
Describe in detail & include copies of equipment certifications
Was any defect with the equipment noted or reported prior to accident/incident
Was any recent maintenance/service performed on this equipment
When/What? Describe in detail and include copies of invoices/work orders
Were standard work procedures followed
Why not - Describe in detail, include additional sheets if necessary and include a copy of the standard site procedures
Was a safety rule or specific instruction violated
What - Describe in detail, include additional sheets if necessary and include a copy of the rule/regulation
When/How was this rule, regulation or specific instruction communicated to the injured worker(s)
#7 Corrective Action Plan
Corrective action(s) and completion date(s)
Date of next scheduled toolbox safety meeting
Name of leader
Has the meeting leader been provided with this information for discussion
#8 Reviewed and acknowledged
Safety Coordinator
Select date
Foreman
Select date
Superintendent
Select date
Project Manager
Select date
#9 Routing - Please Email to
Safety Officer: Frank Zamora, Email: Frank@domeconst.com
Human Resource Director: Virginia Preciado, Email: Virginia@domeconst.com
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Please note that this checklist template is a hypothetical appuses-hero example and provides only standard information. The template does not aim to replace, among other things, workplace, health and safety advice, medical advice, diagnosis or treatment, or any other applicable law. You should seek your professional advice to determine whether the use of such a checklist is appropriate in your workplace or jurisdiction.
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