Personal Injury/Near Miss Report Form
-Call your supervisor
-Get drug test at medical facility
-Please complete this form to report any personal injuries or near-miss incidents.
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Email *
Employee Name Involved *
Report Type *
Date of Incident
MM
/
DD
/
YYYY
Location of Incident *
Project name, project location, service location, etc
Describe what happened (include specific details) *
Were there any injuries? *
If yes, please describe the injuries and affected body parts: *
Was medical attention required? *
If yes, what type of medical attention was received? *
What contributing factors do you believe led to this incident? *
Submit
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