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 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 equiment 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 detail. (MANDATORY) *

Employee Signature (once printed)

Supervisor Signature (once printed)

Please upload pictures of incident (required)

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