Incident Report

Please fill out the form below, upload any pertinent files and click submit. Majority of the fields are required.

Job Number*

Name of Person Completing Report*

Email of Person Completing Report*

Phone Number of Person Completing Report

INCIDENT DETAILS

Type of Incident Report

Name of Person Injured*

Date & Time of Incident*

Time

Did worker report Accident/Incident the same day?*

Address of Incident/Accident*

Contact Name at Incident/Accident Site*

Site Contact Phone Number*

Type of Injury*

Estimated Cost of Property Damage*

Title of Injured/Involved Person*

Injured Person's Phone Number*

Injured Person's Date of Birth

Injured Person's Address*

Nature of Injury/Damage*

Did worker refuse first aid/medical treatment?*

Location/Address where injured employee(s) was/were taken for medical treatment *

Medical Facility Phone Number

Status of Doctor's Release*

Date of next doctor's visit

Post Drug Testing*

Drug testing results*

Did worker refuse testing?*

Was injured worker prescribed medication for injury? *

Was injured worker admitted to hospital?*

List and identity of other law enforcement agencies present at the accident/event site*

Description of accident/event and whether the accident scene or instrumentality has been altered*

Equipment/Tools Involved include brand names model #’s *

Employees/Persons/Contractors Involved Names*

Describe Weather or Area Condition*

Contributing Factors*

Contributing Actions*

Witness Name(s) and Phone Number(s)*

Corrective Action*

General Contractor Name

General Contractor Contact Person

General Contractor Contact Person Phone

Attach doctor’s note, release or other supporting documentation (permits, witness statements, doctors release, photos, etc.)

Number of Supporting Documentation Documents to Upload

Maximum size of each file is 5 MB.

First Document

Second Document

Cal/OSHA Accident Reporting Requirements: Employers must immediately report to Cal/OSHA any work-related death or serious injury or illness. Employers may do so by telephone, 24 hours a day, 7 days a week: https://www.dir.ca.gov/dosh/report-accident-or-injury.html Definition of Serious Injury or Illness: https://www.dir.ca.gov/dosh/Serious-injury-FAQ.html MSHA Accident Reporting Requirements: If an accident, injury or illness occurs at or in conjunction with activity at a mine, independent contractors are required to report the circumstances of the incident to MSHA using this form/link. https://www.msha.gov/support-resources/forms-online-filing/2015/04/14/mine-accident-injury-and-illness-report

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INCIDENT REPORT

Attach doctor’s note, release or other supporting documentation (permits, witness statements, doctors release, photos, etc.)

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