Incident
Equipment/Property Damage
Close Call / Near Hit
Fill Out All Blocks. Be as specific as possible and include drawings, photos, additional
narrative, as needed.
SUPERVISOR CONTACT INFORMATION
Reporting Supervisor / Investigator Name:
(mo/day/yr)
Date of Report: (mo/day/yr)
Contractor involved? If yes, name and contact information:
box and skip this
section.
No injury
Injured Party’s Name & Title:
Injured Party’s Contact Information:
Nature of Injury/Illness:
Dislocation
Heat Related Illness
Name & Address of Treating Dr. / Facility
Bruising Chemical Reaction
Hospital Stay
Scratch/Abrasion Allergic Reaction
Amputation
Concussion
WITNESSES AND/OR WITNESS STATEMENT
Witnesses (name and contact information)
Witness statement attached?
Yes No
List property / material damaged (use control numbers if
available):
Object / substance inflicting damage:
THE INCIDENT (Use Additional Paper as Needed, Reference Below and Attach)
(Investigate scene of incident or conditions. Describe who was involved, when and where the incident happened, what
happened, and how.
)
Incident Reporting and Investigation Form