Equipment Incident Report – Southam and Associates

Today's Date: *

Name *

First

Last

Phone *

Date of Incident *

Time of Incident *

Occupation *

Injuries? *

If yes, Kimber 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?

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

What could have been done to prevent the accident?

Please describe the incident in detail. (MANDATORY) *

Employee Signature (once printed)

Supervisor Signature (once printed)

INCIDENT REPORT