Tri-City Electric Co.

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INITIAL ON-SITE ACCIDENT/INCIDENT REPORT

First Name: *

Last Name: *

Date Of Birth: *

Home Phone: *

Occupation: *

Address:

Date Of Accident: *

Time Of Accident:

AM PM

Date Of Report: *

Date Of Hire:

Jobsite and Specific Location of Accident: *

Nature of Injury and Body Part: *

Summary of Injury – Describe the events leading up to the injury, the nature of the injury, the object that directly caused harm, and the task taking place:

List Any Equipment or Tools Damaged:

How Could This Accident Have Been Prevented?

Key Lessons Learned:

Corrective Action:

First Aid Administered and By Whom:

Name of Hospital or Clinic if Needed:

Witness Name:

Phone Number:

Witness Name:

Phone Number:

Witness Name:

Phone Number:

Additional Comments:

Signature:

Clear signature

Date:

Supervisor:

Clear signature

Date:

Safety Director:

Clear signature

Date:

INITIAL ON-SITE ACCIDENT/INCIDENT REPORT

Employee Imformation

Description Of Accident