Operations Incident Report - General Liability
Incident Information
Incident Date:
*
Incident Time:
Type of Incident:
*
Water
Electrical
Fire
Collision
Underground Damage
Other
Emergency Response Called:
Police
Fire
EMS
Incident No:
Emergency Response Contact Name:
Telephone No:
Incident Location (Address/City/State/Zip):
Incident Occured On:
*
Brandt Jobsite
Brandt Service Site
Brandt Warehouse/Shop
Other
Job/ Site Name:
*
Job #(if applicable):
*
Is Job Covered Under a CIP?:
Yes
No
If Yes, Contact & Telephone:
Any injuries associated with the incident?
Yes
No
If yes, please fill out Brandt Injury Form.
Was a Brandt vehicle associated with the incident?
Yes
No
If yes, please fill out Brandt Auto Accident Report.
Employee Information
Temp Employee?
*
Yes
No
First Name:
*
Last Name:
*
Date of Birth:
*
Employee ID:
Department:
*
Job Title:
*
Start Date:
Time in Trade:
Employee's Telephone No:
Supervisor Name:
*
Substance Screen / BAC Completed?:
*
Yes
No
If Not, Reason?
Other Employees Involved:
*
Yes
No
If Yes, Name & Telephone:
Witness(es)?
*
Yes
No
If Yes, complete Witness Statement Form.
Where did the incident occur on the premises/property?
(explain in detail)
*
Employee Statement
*
Employee's statement of the incident:
(provide as much detail as possible)
*
If the employee did not complete a statement, reason(s) for not completing statement?
*
Describe the damages, or consequences (if known), of the incident:
(provide as much detail as possible)
*
PRIVILEGED AND CONFIDENTIAL
Additional Information
What was the person doing when the incident occurred
(explain in detail, including any tools/equipment being used, as well as what let up to the incident)
*
What is your understanding of how the incident occured?
*
Work Area Questions
Did housekeeping/clutter in the work area contribute to the incident?
*
Yes
No
If Yes, (explain below)
Did the employee's working surface contribute to the incident?
*
Yes
No
If Yes, (explain below)
Did the lighting in the area contribute to the accident?
*
Yes
No
If Yes, (explain below)
Did the design or layout of the work area contribute to the incident?
*
Yes
No
If Yes, (explain below)
Were there additional conditions in the area that contributed to the accident?
*
(equipment/material,environmental/weather)
Yes
No
If Yes, (explain below)
Equipment Questions
Was equipment used in accordance with manufacturer's requirements and/or procedures or training?
*
Yes
No
If No, (explain below)
Was equipment operationally ready per recommended maintenance and manufacturer's guidelines?
Yes
No
If No, (explain below)
Were guards in place on equipment? (if applicable)
*
Yes
No
If No, (explain below)
Was the employee using the tools & equipment required for the task?
*
Yes
No
If No, (explain below)
Was appropriate training provided to the employee to accomplish the task?
*
Yes
No
If No, (explain below)
Upload Pictures
*
Add Image
Employee Signature:
Clear Signature
Date of Employee's Signature:
Investigation Completed By:
Date of Completion:
Regional Safety Director:
Late Report?
*
Yes
No
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