HTML Preview Construction Incident Investigation Report page number 1.
Injury
Incident
Equipment/Property Damage
Close Call / Near Hit
Fill Out All Blocks. Be as specific as possible and include drawings, photos, additional
narrative, as needed.
Building:
CP:
SUPERVISOR CONTACT INFORMATION
Reporting Supervisor / Investigator Name:
Title:
Directorate / Dept:
Ext:
Mailstop:
Date of Incident:
(mo/day/yr)
Time of Incident:
a.m.
p.m.
Time of Report:
a.m.
p.m.
Date of Report: (mo/day/yr)
Contractor involved? If yes, name and contact information:
INJURED PARTY
If no injury, check
box and skip this
section.
No injury
Injured Party’s Name & Title:
Injured Party’s Contact Information:
Nature of Injury/Illness:
Dislocation
Heat Related Illness
Treatment:
Name & Address of Treating Dr. / Facility
Strain/Sprain
Internal
Other (Specify)
First-Aid
Fracture
Burn/Scald
E. R.
Laceration/Cut
Foreign Body
Dr.’s Office
Bruising Chemical Reaction
Hospital Stay
Remarks:
Scratch/Abrasion Allergic Reaction
Body Part Injured(s):
Amputation
Concussion
WITNESSES AND/OR WITNESS STATEMENT
Witnesses (name and contact information)
Witness statement attached?
Yes No
PROPERTY DAMAGE
List property / material damaged (use control numbers if
available):
Nature of damage:
Object / substance inflicting damage:
Approximate cost:
THE INCIDENT (Use Additional Paper as Needed, Reference Below and Attach)
Describe what happened.
(Investigate scene of incident or conditions. Describe who was involved, when and where the incident happened, what
happened, and how.
)
10/12/10, Page 1of 3
Incident Reporting and Investigation Form
Company Name/Logo: