Universal Accident/Incident Report

Incident Document Type:(Required)

On-site Prime Contractor Name:(Required)

Your Name:(Required)

Vehicle Incident/Accident Location

Date of Incident:(Required)

Time of Incident:(Required)

Please describe the location of the incident:(Required)

Company Vehicle Information

Year:(Required)

Make:(Required)

Model:(Required)

Mileage:(Required)

VIN:(Required)

Registration #:(Required)

Employee Driver Information

Name:(Required)

First Last

Phone:(Required)

Driver License Number:(Required)

Home Address:(Required)

Street Address City State / Province / Region ZIP / Postal Code Country

Other Vehicle Information:

Year:(Required)

Make:(Required)

Model:(Required)

Mileage:(Required)

VIN:(Required)

Registration Number:(Required)

Other Driver Information:

Name:(Required)

First Last

Phone:(Required)

Driver License Number:(Required)

Home Address:(Required)

Street Address City State / Province / Region ZIP / Postal Code Country

Please upload a picture of the other party's driver license:(Required)

Injuries

Were there any injuries which occured as a result of the vehicular accident/incident?(Required)

Please list the name, age, home address, and phone number of any injuried parties:(Required)

Please describe the nature and extent of the injuries:(Required)

Were emergency services contacted as a result of the accident/incident?(Required)

Accident/Incident Details

Direction your vehicle was traveling:(Required)

Direction other vehicle was traveling:(Required)

Your Approximate Speed:(Required)

Other Party Approximate Speed:(Required)

Weather at the Time of Incident:(Required)

Road Condition at Place of Incident:(Required)

Were Police or Highway Patrol Called to the Scene of the Incident?(Required)

Report Number:(Required)

Please include an image of the police report.(Required)

Attach diagram of the accident to include: position of each vehicle, injured persons, locations of sidewalks and street intersections, and relative compass direction. A picture or overhead view (Google Maps) can assist in further description of the accident location.(Required)

Please upload pictures of the accident/incident from as many angles as possible. Please capture the other party's vehicle damage, your vehicle damage, street signs (including speed limit, one way, merge arrows, etc.), street names, intersection details, and any other images which may help clarify the inciden/accident.(Required)

Utility Strike Investigation

Date(Required)

Project Name and Number:(Required)

Was a subcontractor responsible for the strike?(Required)

Subcontractor Name:(Required)

Subcontractor Supervisor Name:(Required)

First Last

What was the immediate impact to people, property, or the community?(Required)

What utilities were impacted?(Required)

Other:(Required)

What was the underground depth of the utility?(Required)

Other:(Required)

What was the size of the utility line encountered?(Required)

Other:(Required)

Was the utility in service at the time of the incident?(Required)

What was the utility casing made of?(Required)

Other:(Required)

Was the utility marked?(Required)

What type of soil was found surrounding the utility?(Required)

Other:(Required)

Who performed the utility locate?(Required)

Outside Company:(Required)

What methods were used to locate the utility?(Required)

Other:(Required)

What methods were used for the excavation/installation?(Required)

Other:(Required)

Are detection instruments an integral part of machinery?(Required)

Did the operator recieve proper briefing of existing underground interferences prior to the start of work?(Required)

Has current boring operator been trained and certified by the employer on the equipment used?(Required)

Does the subcobtractor have previous experience in ghe market?(Required)

Was the calling tree utilized?(Required)

Was there a project field construction manager on site at the time of the incident?(Required)

Project Field Construction Manager Name:(Required)

First Last

Please upload photos of the incident or impact of incident:(Required)

Describe the incident in detail (injuries, location, specific equipment used or damaged, property damage, operators, and employee involved.)(Required)

Incident Report (Injury, Employee Illness, Near-miss)

Date of incident or onset of illness:(Required)

Date reported to employer:(Required)

Time of incident or onset of illness:(Required)

Time employee began work:(Required)

Did the injury or illness cause the employee to miss at least one full day of work due to the injury or illness?

Describe the injury or illness and part of body affected:(Required)

Describe the non-injury close-call:(Required)

Location where event or exposure occurred (number, street, city, zip):(Required)

Street Address City State / Province / Region ZIP / Postal Code Country

Did the incident occur on employer’s premises?(Required)

Department or internal location where event or exposure occurred e.g. (warehouse, telecom, office):(Required)

Were other workers injured or ill in this event?(Required)

Please list the equipment, materials and chemicals employee was using when event or exposure occurred e.g. (scaffold, acetylene, welding torch, etc.):(Required)

Please list the specific activity the employee was performing when event or exposure occurred e.g. (welding seams on metal forms, loading batteries onto truck, etc.):(Required)

Please describe sequence of events and how incident occurred. Specify object or exposure which directly produced the injury/illness e.g. (employee stepped backwards to inspect work and slipped on scrap material. As he fell, he brushed against fresh weld, and burned right hand.)(Required)

Please describe sequence of events and how incident occurred. Specify object or exposure which may have caused an injury.(Required)

Did the employee seek medical attention at a hospital or clinic?(Required)

Name and address of hospital or clinic:(Required)

Street Address City State / Province / Region ZIP / Postal Code Country

Name or attending physician:(Required)

First Last

Attending Physician or Hospital Phone Niumber:(Required)

Was the employee/patient admitted overnight?(Required)

Employee Information

Employee Name:(Required)

First Last

Employee DOB:(Required)

Employee Sex:(Required)

Employee Home Address:(Required)

Street Address City State / Province / Region ZIP / Postal Code Country

Employee Phone:(Required)

Date of hire:(Required)

Occupation:(Required)

Employment Status:(Required)

Employee Statement

Incident Date:(Required)

Project Name and Market:(Required)

Site Number:(Required)

Contractor Name:(Required)

Contractor Field Supervisor Name:(Required)

First Last

Contractor Field Supervisor Email:(Required)

Employee Information:

Your Name:(Required)

First Last

Title or Trade:(Required)

Date of Incident:(Required)

Time of Incident:(Required)

Please describe what happened leading up to, during and after the incident. Use as much detail as possible.(Required)

Witness Statement

Please select your role in observing the incident:(Required)

Project Name/Market(Required)

Site Number:(Required)

Your Employer Name:

Field Supervisor Name:(Required)

First Last

Field Supervisor Email:(Required)

Your Name:(Required)

First Last

Your Phone:(Required)

Your Email:(Required)

Title or Trade(Required)

Date of Incident:(Required)

Approximate Time of Incident:(Required)

Please describe what happened leading up to, during and after the incident. Use as much detail as possible.(Required)

Form Submission

Would you like a copy of this form email to you?

Yes

Signature