INCIDENT REPORT FORM

This form is used to report accidents, injuries, employee behavior and other related concerns. This should be
completed within 24 hours of the incident occurred.

INFORMATION ABOUT THE PERSON INVOLVED IN THE INCIDENT

Who was involved? Employee Name:
Employee
Visitor
Position:
Contractor
Supplier
Other ____________ Project Assigned:

INFORMATION ABOUT THE INCIDENT

Time of Incident Date of Incident
Location of Incident Type of Incident
Date Reported Damage report / Assumed amount

FOR HEAVY EQUIPMENT, UTILITY/SERVICE VEHICLE INCIDENTS

What company property
was involved?
Utility/Service Vehicle
Heavy Equipment
Vehicle Plate Number
Heavy Equipment Model
Heavy Equipment Number

DESCRIPTION OF INCIDENT: (What happened, how it happened, factors leading to the event, etc.) Be specific as possible.
(You may use the back part of this form if necessary.)

*Please attach photograph/Document if possible*

INFORMATION ABOUT THE INFORMANT/WITNESS

NAME
POSITION

__________________________________________________
Name and Signature of the Employee Reporting the Incident

Noted by:
_______________________
Signature over Printed Name
(Dept. Head, PIC and\or Project Manager)

*If the informant/witness wants to remain anonymous, please state reason:

____________________________________________________________________________________

ACTION TAKEN (Please don’t mark this portion for Person’s Authority use only.)
Report Received Date: _________________

REMARKS
_____________________________________________________________________________________________
___________________________________________________________________________
ACTION TO BE TAKEN
VERBAL WARNING SUSPENSION (____ Days)
WRITTEN WARNING DISMISSAL