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INCIDENT NUMBER
PROPERTY DAMAGE INCIDENT REPORT
Date of Incident: Time of Incident:
Date Safety Notified: Time Reported to Safety:
Superintendent / Foreman: Division:
Project Manager: Project Number:
Location of Accident/Incident:
EMPLOYEE DATA
Employee Name: Phone:
Job Title: Years’ Experience:
Drug Screen Administered: If No, Please Indicate Reason:
Type of Equipment Operated: Equipment #:
PROPERTY DAMAGE INFORMATION
Describe in detail the circumstances of the incident. Give a chronological sequence of events. If materials, equipment
and/or vehicles were involved, start before they were brought to the incident scene and describe who, what, where, when,
how, and why the incident happened in your words below.
Brief Description of Damages: Cause of Damage
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Property Owner Information Insurance Information
(Name, Address, City/State/Zip, Phone) (Company, Address, City/State/Zip, Phone, Contact)
Company Involved in Incident:
Estimated
Description of Damaged Property (Please include Make/Model/Year) License / Equipment #
Damage:
Total Estimated Damages:
WITNESS INFORMATION
Are There Any Witnesses? Total Number of Witnesses
Note: All Witnesses MUST complete at Employee/Witness Statement – Click Here To Download
Witness 1: Witness 2:
(Name, Address, City/State/Zip, Phone): (Name, Address, City/State/Zip, Phone):
ADDITIONAL NOTES / COMMENTS
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REFERENCE GUIDE
POTENTIAL CONTRIBUTING FACTORS
Use the listing below as an aid in identifying the factors that contributed to the incident.
This is a reference guide to assist with completing the “Incident Analysis Review” on the following page.
PROCEDURES COMMUNICATION FACILITIES/EQUIPMENT
None Developed Insufficient planning within THA Faulty equipment
Breakdown in communication between
Developed, not followed Poor Design
workers
Breakdown in communication between
Developed, not trained Not inspected sufficiently
workers & supervisor
Breakdown in communication between
Developed, not understood Ergonomic factors
work teams
Developed, not accurate Confusion after communication New equipment
Developed, unable to follow Change in process/materials
IN A HURRY HAZARD OTHER FACTORS
Created by co-worker, worker or other
Supervisor implied need Weather/temperature
trade
Employee perceived need Created by external factors Working long hours
Friendly competition Documented but not repaired Physical over exertion
Due to external factors Unidentified Personal Protective Equipment
Workload too heavy Identified but accepted Improper body position
Lack of teamwork Deficient repair Light
Customer originated Conditions changed without knowledge Noise
Equipment failure Improper communication Atmosphere
Rushes deadlines Lack of documentation Visibility
Lack of help or assistance Chemical
Illness Insufficient training
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INCIDENT ANAYLSIS REVIEW
Contributing Factor(s) to the Incident: List the Corrective Action(s) taken to prevent
Refer to “Potential Contributing Factors” list as a reoccurrence for each contributing factor
reference guide. Please document all contributing factors.
1. 1.
Due Date:
2. 2.
Due Date:
3. 3.
Due Date:
4. 4.
Due Date:
5. 5.
Due Date:
6. 6.
Due Date:
7. 7.
Due Date:
8. 8.
Due Date:
Based upon the contributing factors identified above, which ONE if removed, triggered all other events to occur, this is the root cause.
What was the Root Cause(s) of the Incident? Corrective Action
Due Date:
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PARTICIPANTS OF THE INCIDENT ANALYSIS
Name Company Trade/Craft Date
NOTES / ADDITIONAL COMMENTS
MANAGEMENT REVIEW
Title Signature Date
First Line Supervisor
Superintendent
Project Manager
Onsite Safety Representative:
(If applicable)
Other:
Other:
Claims Administrator:
Safety Manager:
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