Construction Accident / Incident Report

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Construction Accident / Incident 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