Incident Notification Form

Incident Notification Form
DRAFT

This report will remain in draft form until the investigation is complete and the accuracy of the evidence has been verified.
State Incident Occurred In?
Business Unit Where Incident Occurred
Supervisor Name

First NameLast Name
Supervisor Email
example@example.com
Incident Type
Type of injury
Location of Injury
Describe the Info Only Event
Site/Project Name Where Incident Occurred
Project Number (if applicable) Where Incident Occurred
Report Status
Date of Incident

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Time of Incident

Hour Minutes

AM/PM Option
Date Reported to Supervisor

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Name of Involved Person (IP)
First/Last
Involved Person DOB

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Last 4 of IP SSN
Phone Number of IP
Please enter a valid phone number.Format: (000) 000-0000.
IP Date of Hire

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
IP Years Industry Experience
IP Home Address (injuries only)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
IP Pay Rate
Does the IP Speak English
Gender of (IP)
Occupation of (IP)
Has IP Completed the Safety Orientation?
Weather Conditions
Ground Conditions
slippery, muddy, dry, ice, etc.
What was Stolen?
Law Enforcement Agency Involved
Police Case #
Who Case Managed the Injury
Name of Case Worker or WorkCare
Where Was IP Treated
Clinic Name
Care Provider Details
Dr. Name; Facility Phone; Address; Type of Facility (Urgent Care, ER, Family Clinic, Etc.)
Type of Damage
What Caught on Fire
Ignition Source
What Was Damaged by Fire
Type of Reputation Damage
How Many Vehicles Were Involved
Types of Vehicles Involved
Vehicle VIN
Extent of Vehicle Damage
Specific Location of Incident
Please be specific
Company(s) Involved
Description of Incident
Witness(s)
Worker Comp Provider
Worker Comp Claim Number
Order of Events
Upload Email

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Upload Photos or Videos

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Upload Witness Statements

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Upload Other Files

Emails; Police Reports; Sub-Contractor Reports; Client Statements; etc.
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Investigation
Does this incident require an RCA?
Upload Investigation Report

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Lead Investigator

First NameLast Name
Investigation Team
What Happened
One sentence description of event or problem
Fishbone Categories
- People – Contributing Factors (Select all that apply)
- Other
- Process – Contributing Factors (Select all that apply)
- Other
- Equipment – Contributing Factors (Select all that apply)
- Other
- Materials – Contributing Factors (Select all that apply)
- Other
- Environment – Contributing Factors (Select all that apply)
- Other
- Management – Contributing Factors (Select all that apply)
- Other
- Measurement – Contributing Factors (Select all that apply)
- Other
- Contributing Factors
- People Contributing Factors
- Process Contributing Factors
- Equipment Contributing Factors
- Materials Contributing Factors
- Environment Contributing Factors
- Management Contributing Factors
- Measurement Contributing Factors
- Contributing Cause(s) (Why did it Happen?)
- Ultimate Root Cause(s) (Why the Contributing Causes(s) existed)
- Summary of Ultimate Root Cause(s)
- Corrective Action(s)
- Who Closed This Incident Report?
  First/Last
- Date Closed
  
  MonthDayYear
  2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

Incident Notification Form

Investigation

Fishbone Categories

Contributing Factors