Incident Form - Property Damage
Incident Date:
*
Incident Time:
Type of Incident:
*
Water
Collision
Fire
Electrical
Other
Late Report?
Yes
No
Classification Of Incident:
Brandt Owned
Rental
Subcontractor
Other
Employee Information
Temp Employee?
*
Yes
No
First Name:
*
Last Name:
*
Date of Birth:
*
Employee ID:
Department:
*
Job Title:
*
Start Date:
Time in Trade:
Involved Employees Contact Number:
Supervisor Name:
*
Other Employees Involved:
No
Yes, Whom:
Substance Screen / BAC Completed?
Yes
No
Incident Information
Where did the Incident Occur?
Brandt Job Site
Brandt Service Site
Brandt Warehouse/ Shop
Non Brandt Site
Job/ Site Name:
Job #:
Job/ Site Address:
Project Manager:
Where did the incident occur on the premises/property?
(explain below)
What was the person doing when incident occurred?
(explain below, be specific- identify tools, equipment or materials the employee was using?)
How did the incident occur?
(Explain below, please describe fully the event that lead up to the incident)
Describe in full detail the damages or consequences of the incident below:
Where there injuries associated with this incident?
No
Yes (Was the Brandt injury form filled out?
Work Area Questions
Did housekeeping/clutter in the work area contribute?
N/A
No
If yes, (explain below)
Did the employee's working surface contribute to the event?
N/A
No
If yes, (explain below)
Was the employee's working surface proper for the task?
N/A
Yes
If No, (explain below)
Did the lighting in the area contribute to the accident?
N/A
No
If yes, (explain below)
Were there additional conditions in the area that contributed to the accident?
(equipment/material,environmental/weather)
N/A
No
If yes, (explain below)
Equipment Questions
Was equipment used in accordance with manufacturer's requirements and/or procedures or training?
N/A
Yes
If No, (explain below)
Were guards in place on equipment?
N/A
No
Yes
Was equipment operationally ready per recommended maintenance and manufacturer's guidelines?
N/A
No
Yes
Did the design or layout of the work area contribute to the incident?
N/A
No
If yes, (explain below)
Was the employee using the tools & equipment required for the task?
N/A
Yes
If No, (explain below)
Was appropriate training provided to accomplish the task?
N/A
Yes
If No, (explain below)
Upload Pictures
Upload Pictures
Add Image
Employee Statement
Did the employee complete a statement?
Yes
No
If yes, employee shall explain in detail what happened & sign statement.
Employee Signature:
Clear Signature
Date employee statement was completed:
Investigation Completed By:
Signature of Investigator:
Clear Signature
Witness Statement
Was there a witness?
No
Yes
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