If there is an incident or injury, first ensure everyone is safe. Immediately notify your Foreman or Site Safety Manager, then complete this form.

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Full Name (person completing this form) *

Your full name

Name(s) of person(s) involved *

Date of Incident *

MM/DD/YYYY (example: 06/11/2026)

Project / Exact Location *

Type of IncidentInjuryProperty DamageEquipment DamageNear MissOther

Detailed description of what happened *

Be as specific as possible

Names of any witnesses

part Exact description

Injury details (if any) – body part and severity

Was medical treatment provided? Describe

What do you think caused this?

Submit