Smith and Associates Environmental Health and Safety Consulting Services

(510) 670-0809

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Wine & Agriculture
General Industry

Staffing Safety Professionals Full/Part Time
ISNetworld Assistance
OCIP Safety Management
Insurance Safety Support
Safety Program/IIPP Development
Storm Water Services

Incident Report

Please fill out the form below, upload any pertinent files and click submit. Every field is required.

*Required Fields

Company Name:
Phone Number:
( ) - *
Name of Person Reporting:
Email Address of Person Reporting:
Phone Number of Person Reporting:
( ) - *
Date of Incident/Accident:
Pick A Date *
Time of Incident/Accident
: *
Did worker report Accident/Incident the same day?:
Address of Incident/Accident:
Contact Name at Incident/Accident Site:
Site Contact Phone Number:
( ) - *
Type of Damage:
Estimated Cost of Property Damage:
Name of Person Injured:
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:
Pick A Date *
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:
If OSHA reportable (admitted to hospital, etc.):
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.):

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