FER Incident / Accident Report

Incident / Accident Report

Project:

Location:

Date:

Time:

Name (Reporter):

TYPE OF INCIDENT

INCIDENT / PERSONNEL INJURY

Name: Position:

Personnel Injured?

Yes No

Location of Injury (body):

PPE Requirement Met?

Yes No

Extent of the Injury:

Treatment Provided:

First Aid Site Nurse Hospital/ER

DESCRIPTION OF INJURY

DESCRIPTION OF TREATMENT FOR INJURY

DESCRIPTION OF THE ACCIDENT / INCIDENT

EQUIPMENT

Equipment Involved?

Yes No

Equipment Number:

Equipment Owner:

FER Other

Type of Equipment:

Buggie Vehicle Other

If other, describe:

WITNESS NAMES

ATTACHMENTS

Employee / Contractor Statement Witness Statements Preliminary Report Other

COMMENTS

SAFETY DEPARTMENT USE ONLY

Classification:

First Aid Recordable Report Only OSHA Illness

Medical Only Lost Time OSHA Injury

Name: Position: Date:

Reporter Signature

Name:

Signature (draw below):

Date: