Incident Report - Smith & Associates

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

Type of Incident Report *

Company Name *

Company Address *

Company Phone Number

Name of Person Completing Report

Email of Person Completing Report *

Email

Confirm Email

Phone Number of Person Completing Report

Date & Time of Incident *

Time

Did worker report Accident/Incident the same day? *

Project Name *

Address of Incident/Accident *

Contact Name at Incident/Accident Site *

Site Contact Phone Number *

Type of Injury *

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

Note: Leave blank if unknown.

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

Note; Leave blank if not applicable.

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