"SAFETY CONSULTANTS SERVING INDUSTRIES SINCE 1989!"  
 

Smith and Associates Environmental Health and Safety Consulting Services

(510) 670-0809

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Construction
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Staffing Safety Professionals Full/Part Time
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Insurance Safety Support
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Incident Report

Please fill out the form below, upload any pertinent files and click submit. Every field is required.

*Required Fields

Company Name:
Address:
Phone Number:
( ) - *
Name of Person Reporting:
Email Address of Person Reporting:
*
Phone Number of Person Reporting:
( ) - *
Date of Incident/Accident:
Pick A Date *
Time of Incident/Accident
: *
Did worker report Accident/Incident the same day?:
Address of Incident/Accident:
*
Contact Name at Incident/Accident Site:
*
Site Contact Phone Number:
( ) - *
Type of Damage:
Estimated Cost of Property Damage:
Name of Person Injured:
*
Title of Injured/Involved Person:
*
Phone Number of Injured Person:
( ) - *
Nature of Injury/Damage:
*
Did worker refuse first aid/medical treatment?:
*
Location/Address where injured employee(s) was/were taken for medical treatment:
*
Medical Facility Phone Number:
( ) - *
Status of Doctor's Release:
*
Date of next doctor's visit:
Pick A Date *
Post Drug Testing:
Drug testing results:
Did worker refuse testing?:
Was injured worker prescribed medication for injury?:
*
Was injured worker admitted to hospital?:
*

List and identity of other law enforcement agencies present at the accident/event site:

Description of accident/event and whether the accident scene or instrumentality has been altered:

Equipment/Tools Involved include brand names model #’s:

Employees/Persons/Contractors Involved Names:

Describe Weather or Area Condition:

Contributing Factors:
Contributing Actions:
Witness Name(s) and Phone Number(s):
Corrective Action:
If OSHA reportable (admitted to hospital, etc.):
General Contractor Name:
General Contractor Contact Person:
General Contractor Contact Person Phone:
( ) -

Attach doctor’s note, release or other supporting documentation (permits, witness statements, doctors release, photos, etc.):


 
 
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