Construction Forms

Incident Report

When to complete: Jobsite and Non-Jobsite Incident with or without Injuries, Property Damage, Jobsite Equipment Failure

In case of emergency call 911

Company Code*

General Information About The Incident

Date of Incident*

Incident Time*

Branch*

Date Incident Reported*

Address/Location of Incident*

City*

State*

Zip*

Description of Incident*

Photos Related to Description

Signatures

Employee Printed Name*

Employee Signature*

Branch Manager/Supervisor Printed Name

Branch Manager/Supervisor Signature

Can be completed later if supervisor is not available

Incident Information (Complete all information that applies to the incident.)

Employee/Driver Making Report (Your Name)*

Home/Cell Phone*

Unit Number/License Number

Contractor/Customer (Who You Are Working For)

Phone#

Property Damage

Select

Other Vehicle/Property Insured

Select

Is Vehicle Drivable

Select

Describe Property

Unit Number Only

Describe Damage

Report/Case #

Owners Name/Address/Phone#

Is Anyone Injured?

Name/Address

Phone

Extent of Injuries

Did the employee seek medical attention?

Select

Does the employee permit a company representative to attend medical treatment?

Select

Part of Body Affected

Front

Back

Witness Information

Name & Address

Phone

Name & Address

Phone

Photos / Evidence

Internal Use Only

All Supporting Documentation Sent to Safety Dept

Select