Contractor Business Name Exact Location of Incident Date Date Investigated Date of Last Time in Position Reported (D/M/Y) Revision (D/M/Y) Years: Months/Days: (D/M/Y) Cost Estimate: Property / Equipment Damage $ Risk Level High Low What was the risk level of this incident? 1 1 2 3 4 (please choose (use reference material located on the last page of this form) one) What could have been the potential severity level? 2 1 2 3 4 (please choose one) Cause Analysis Primary Type of Incident (select one) Struck against Contact with Overstress, overpressure, overexertion, ergonomic (electricity, heat, cold, (running, bumping into) radiation, caustics, toxics, biological, Struck by Caught in Violence noise) (hit by (pinch & nip points) moving object) Fall from elevation Caught between / under Non-specific (crushed to lower level or amputated) Fall from same Environmental release Other level (slips & fall, trip over) Injury Information (select all that apply) Nature of Injury Allergies / sensitivities Cut / puncture / open wound Hernia / rupture Amputation Dislocation Infection Asphyxiation Electric shock Respiratory conditions Bruise / contusion Foreign body Scratch / abrasion Burn Fracture Sprains / strains – joints, muscles Concussion Hearing loss Other occupational injuries Body Part Abdomen L R Face L R Neck L R Ankle L R Hand L R Shoulder L R
Contractor Business Name Exact Location of Incident Date Reported (D/M/Y) Date Investigated (D/M/Y) Date of Last Revision (D/M/Y) Time in Position Years: Months/Days: Cost Estimate: Property / Equipment Damage $ Risk Level (use reference material located on the last page of this form) High Low 1 What was the risk level of this incident? (please choose one) 1 2 3 4 2 What could have been the potential severity level? (please choose one) 1 2 3 4 Cause Analysis Primary Type of Incident (select one) Struck against (running, bumping into) Contact with (electricity, heat, cold, radiation, caustics, toxics, biological, noise) Overstress, overpressure, overexertion, ergonomic Struck by (hit by moving object) Caught in (pinch & nip points) Violence Fall from elevation to lower level Caught between / under (crushed or amputated) Non-specific Fall from same level (slips & fall, trip over) Environmental release Other Injury Information (select all that apply) Nature of Injury Allergies / sensitivities Cut / puncture / open wound Hernia / rupture Amputation Dislocation Infection Asphyxiation Electric shock Respiratory conditions Bruise / contusion Foreign body Scratch / abrasion Burn Fracture Sprains / strains – joints, muscles Concussion Hearing loss Other occupational injuries Body Part Abdomen L R Face L R Neck L R Ankle L R Hand L R Shoulder L R