Equipment Incident Report

Today's Date: *

Name *

First

Last

Phone *

Date of Incident *

Time of Incident *

Occupation *

Injuries? *

If yes, HR will need to send you an additional First Report of Injury that needs to be filled out.

Job Name AND/OR location of incident *

Type of Accident *

Check all that apply

Is there currently a hazardous situation on site? *

If yes, explain below

Explain hazardous situation, if applicable

Has your Project Manager/Superintendent been notified of a hazard? *

What equipment/vehicle was involved? *

Was there any property damage? *

Pictures are required. Do you have pictures? *

Why did the incident happen? What were the conditions? *

If you chose "other" please explain below

Why did the incident happen? Was it due to human error? *

If you chose "other" please explain below

What could have been done to prevent the accident? *

If you chose "other" please explain below

Please describe the incident in FULL detail. (MANDATORY) *

Employee Signature *

Clear Signature

Please upload pictures of incident (required)

Click or drag files to this area to upload. You can upload up to 6 files.