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 NameLast Name
Employee Involved*

First NameLast Name
Date of Incident*

DayMonthYear
Time of Incident

:HourMinutesAM/PM Option
Detailed Location*
Describe Incident*
Pictures or Sketches available?

YesNo
Witness Statements Taken?

YesNo
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.

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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 MissFirst AidInjuryProperty DamageDamage & Injury
Property Damage
What type of property damage?

Utility StrikeChemical SpillVehicle / Equipment AccidentOther
Were there any injuries?

YesNo
Describe
Type of Utility Strike

UtilityElectricalGas
Were locates completed?

YesNo
Were they accurate?

YesNo
Time repair ordered

:HourMinutesAM/PM Option
Confirmation #
Type of Chemical Spill

ChemicalBiologicalOther
Corrective Actions Taken
Was another vehicle involved?

YesNo
Our Vehicle Unit #
Unit Description
Description of Damage
OTHER VEHICLE
Year & Make
Plate #
Insurance Policy #
Insurance Carrier
Driver's License #
Full Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number

Area CodePhone Number
Was it towed?

YesNo
To where?
Reported to Police?

YesNo
Police Officer
Case #
First Aid Report and/or Medical Care Report
First Aider Name

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

YesNo
If Yes, for how long?
Was this based on personal observation?

YesNo
Did the worker refuse further medical care?

YesNoNot Applicable
Transported to
Transported by
Reported to WCB?

YesNo
WCB Claim #, if known
Should be Empty:

Incident Report

Property Damage

First Aid Report and/or Medical Care Report