Incident Report

Incident Report
Please fill in as much information as you can. Some fields are required and are marked with a star.

Based on your selections as you fill out the form only the appropriate fields will appear.
Your Name *

First Name Last Name
Employee Involved *

First Name Last Name
Date of Incident *

Day Month Year
Time of Incident

: Hour Minutes AM/PM Option
Detailed Location *
Describe Incident *
Pictures or Sketches available?

Yes No
Witness Statements Taken?

Yes No
Please submit any photos, witness statements, or any other relevant documenation you may have.

You may submit up to THREE files. To submit multiple files, click upload and select your first file. Then click upload again.

MOBILE FRIENDLY.
Upload Files

Upload a File

Cancel of
DEFINITIONS

Near Miss - a potential injury or property damage (eg. tripping hazards, tools falling without hitting somebody)

First Aid - a minor injury requiring first aid but not transportation to a medical facility

Injury - an injury that required transportation to a medical facility and may result in lost time

Property Damage - damage to property without injury

Damage & Injury - damage to property with an injury that requires first aid or medical treatment
Type of Incident

Near Miss First Aid Injury Property Damage Damage & Injury
Property Damage
What type of property damage?

Utility Strike Chemical Spill Vehicle / Equipment Accident Other
Were there any injuries?

Yes No
Describe
Type of Utility Strike

Utility Electrical Gas
Were locates completed?

Yes No
Were they accurate?

Yes No
Time repair ordered

: Hour Minutes AM/PM Option
Confirmation #
Type of Chemical Spill

Chemical Biological Other
Corrective Actions Taken
Was another vehicle involved?

Yes No
Our Vehicle Unit #
Unit Description
Description of Damage
OTHER VEHICLE
Year & Make
Plate #
Insurance Policy #
Insurance Carrier
Driver's License #
Full Name

First Name Last Name
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Phone Number

Area Code Phone Number
Was it towed?

Yes No
To where?
Reported to Police?

Yes No
Police Officer
Case #
First Aid Report and/or Medical Care Report
First Aider Name

First Name Last Name
Describe Injury
Describe First Aid Provided
Was the injured unconscious?

Yes No
If Yes, for how long?
Was this based on personal observation?

Yes No
Did the worker refuse further medical care?

Yes No Not Applicable
Transported to
Transported by
Reported to WCB?

Yes No
WCB Claim #, if known
Should be Empty:

Incident Report

Property Damage

First Aid Report and/or Medical Care Report