When submitted, form responses are sent to the email addresses provided and then deleted.
IF YOU WISH TO RETAIN THE INFORMATION YOU HAVE ENTERED, ADD AN EMAIL ADDRESS BEFORE SUBMITTING.

Injury or Illness Incident Report

The Injury or Illness Incident Report is to be completed by the Job Supervisor whenever there is an injury or illness on the job site of sufficient severity to warrant filing this report.

The filing of the report is at the discretion of the Job Supervisor. However, it is recommended that a report be filed for each reported injury or illness incident, no matter the severity. It is better to file a report and not need it than to need a report and not have filed it.

INJURY OR ILLNESS INCIDENT REPORT

SITE SUPERVISOR
Complete upon the occurrence of any injury or illness on the job site.

PROJECT MANAGER
Copy to Project Binder, Copy to Accounting/Risk Management.

ACCOUNTING/RISK MANAGEMENT
File in Safety Compliance folder for minimum 5 years.

Project

Builder

Site Supervisor

Subcontractor

Incident date

We are issuing an Injury or Illness Incident Report

This incident report is for is for:

An accident An illness on the job site

The Subcontractor was notified of the incident.

Yes No

The following information relates to the affected person

Name of the affected party

Age of the affected party

Address of the affected party

Phone of the affected party

Subcontractor Telephone

Subcontractor's Worker's Comp Insurance carrier

The injury or illness incident

Where on the project did the incident take place?

What work was being done at the time of the incident?

If "Other", describe

Full names of any other persons affected in this incident.

Full names of any witnesses to this incident.

Treatment or First Aid provided

Details of treatment or first aid provided

Name of person(s) providing treatment or first aid

Was an ambulance called?

Yes No NA

If so, name of ambulance company

Was the affected person taken to a treatment facility?

Yes No NA

If so, name of the treatment facility

Follow-Up

To whom did you report the incident?

What action is suggested to prevent a recurrence of the incident?

Note 1

Note 2

Note 3

Send to

Site Supervisor

Subcontractor

Project Manager

Risk Management

Copy to

When the “Send Inspection Report” button is selected, an email with all the information in this Inspection Report will be sent to the “Builder email” address of the Company Representative completing this report and to the “Subcontractor email” address and “Copy to” addresses if provided.

When submitted, form responses are sent to the email addresses provided and then deleted. IF YOU WISH TO RETAIN THE INFORMATION YOU HAVE ENTERED, ADD AN EMAIL ADDRESS BEFORE SUBMITTING.

Injury or Illness Incident Report

The Injury or Illness Incident Report is to be completed by the Job Supervisor whenever there is an injury or illness on the job site of sufficient severity to warrant filing this report.