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

Up to 10 photos for this section (separate from Photos / Evidence below).

Up to 10 photos. Phone photos are resized automatically.

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

Witness statement and signature are optional.

Witness 1

Name & Address

Phone

Statement (optional)

Printed Name (optional)

Witness 1 Signature (optional)

Witness 2

Name & Address

Phone

Statement (optional)

Printed Name (optional)

Witness 2 Signature (optional)

Photos / Evidence

Up to 10 photos for this section (separate from description photos above).

Up to 10 photos. Phone photos are resized automatically.

Internal Use Only

All Supporting Documentation Sent to Safety Dept

Select