Injury Report

Injury Report of a First Aid, Medical Treatment/Return to work, Restricted Work, Modified Duties, Lost Time or Fatality Report

Day Of The Week*

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Time of Day*

12HR Format (HH:MM)

Reported By

First and last name

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Product Line/Division*

Select Main Division Experiencing Event

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Incident / Accident Details

Injury / Illness Classification

N/A

Loss Experienced*

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Main Activity At Time of Event*

Select all that apply

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Incident Information

Client / Customer*

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Location of Incident*

Lease Location or Specific Area

Equipment / Unit #

Select all that apply including trailer #

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Lost Time/NPT (Hours)

Field Supervisor

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Lead Operator

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Incident Description

(use smartphone mic to verbally describe incident details if available)

Detailed Account Of The Event

Describe the incident/accident/event in detail

Unsafe Acts*

If Other Selected Please Explain

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Unsafe Conditions*

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Management Deficiencies

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Severity of the Event*

Catastrophic

Very Serious

Serious

Minor

Frequency of Task*

Few times per job

Once per job

Occasionally during the week

Few times a Month

Supervisors Name of Injured Person

Name Of Injured Person

First Name, Last Name

Phone Number of Injured Person

Age of Injured Person

Job Title of Injured Person

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Division Injured Person is Employed*

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Length of Employment in Current Position

Employee Classification

Full Time

Part Time

Contract

Temporary

Nature of Injury

Select all that apply

Select

Body Part Injured

Select all that apply

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Injury Source

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Secondary Source of Injury

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Supporting Documents*

Documents required & provided with report; Sslect all that apply

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File Upload

Attach supporting photos & documents

Drag and drop files here or

Incident Analysis

Management Investigation Office Use only

Product Line Manger*

Please Select Your Product Line Manager

Select

Send me a copy of my responses

Incident / Accident Details

Incident Information

Crew Information

Incident Description

Contributing Causes

Risk Assessment

Injury Details

Supporting Evidence

Incident Analysis