Incident Report

Emergency Numbers: Fire, Police and Ambulance 911 Perficut Nurse Triage Hotline 1-855-921-9519 (open 24/7 to answer what type of care is best for the issue) Department of Transportation (515) 967-4246 Environmental Protection Agency/Spill (913)-281-0991 Natural Response Center (800)-424-8802 Department of Natural Spill Emergency (515)-725-8694 Fill out this form within 24 hours of the incident. *ASSUME THIS FORM MAY BECOME A PUBLIC RECORD*

Contact Information

This section is filled out to understand more about who completed this form.

Person Completing Report

Department

Address

City

State

Zip

Mobile Phone

Select what you are:

Incident Information

Type of Incident

Name of Employee Involved

Comments

Date of Incident

mm/dd/yyyy

Time of Incident

Time of Incident (AM/PM)

Time Employee Clocked In

In-Depth Description of Incident

Were any hazardous materials spilled during the incident?

If yes on hazardous material spill, please provide details of the spill.

Incident Location

Location of Incident

Location Address

Location City

Location State

Location Zip

Medical Treatment Information

Fill this section out only if employee received medical treatment.

Name of Physician/Health Care Provider

Physician Address (city/state/zip)

Physician Phone Number

Conditions

Did weather conditions play a role in the incident?

Select the conditions that existed at the time of incident:

Clear

Cloudy

Ice

Low Visibility

Rain

Snow

Other

Comments on conditions

Vehicle Incident Summary

Perficut Vehicle # and License Plate #

Other Party License Plate #s

Incident Comments

Medical Incident and Person Injury

What was the nature of the injury?

What part of the body was injured?

How did the incident occur?

What was the individual doing before the injury?

What equipment was being used, if any?

Comments.

Party 1 Information (if applicable)

Party 1 Name

Party 1 Address

Party 1 City

Party 1 State

Party 1 Zip

Party 1 Mobile

Party 1 Email

Party 1 is a:

Describe injuries if any:

Describe damage to vehicle if any:

Describe damage to property if any:

Party 2 Information (if applicable)

Party 2 Name

Party 2 Address

Party 2 City

Party 2 State

Party 2 Zip

Party 2 Mobile

Party 2 Email

Party 2 is a:

Describe injuries if any :

Describe damage to vehicle if any :

Describe damage to property if any :

Witness 1 Information

Witness 1 Name

Witness 1 Address

Witness 1 City

Witness 1 State

Witness 1 Zip

Witness 1 Mobile

Witness 1 Email

Witness 1 is a

Witness 2 Information

Witness 2 Name

Witness 2 Address

Witness 2 City

Witness 2 State

Witness 2 Zip

Witness 2 Mobile

Witness 2 Email

Witness 2 is a:

What could have been done to prevent the incident?

Acknowledgement of Information

By typing in your first and last name, you acknowledge all of the above information to be true.

Signature

Pictures are required for all incidents:

Take a photo of the other parties insurance card (if any other party was involved). When the scene is safe, photograph the following from the entire scene: 1. From 25’ feet away, close up, in all directions 2. All sides of vehicles, damage areas, license plates, company name, DOT # 3. Any skid marks, traffic control devices, street signs, etc.

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Incident Report | V9 | 8.30.2017

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