INCIDENT / ACCIDENT REPORT

Complete immediately following any injury, illness, near-miss, or property damage. Report serious incidents to the Safety Manager without delay.

Company / Craft

Report #

Date of incident

Time

Project

Job # / Permit #

Supervisor

Exact location on site

Reported by

Date reported

Incident classification

Injured / involved person

Name

Job title

Employer

Phone

Years experience

Body part(s) affected

Nature of injury / illness

Treatment

Description of incident — what happened, in sequence

Task being performed at time of incident

Immediate / direct cause

Contributing factors / root cause

Corrective actions taken / planned

Responsible person

Target date

Task covered by AHA / THA?

AHA / THA #

PPE in use at time of incident

Witnesses

#	Name	Company	Phone	Statement

Sign-off

Prepared by

Print name

clear

Signature

Date

Supervisor

Print name

clear

Signature

Date

Safety reviewed by

Print name

clear

Signature

Date

GEC2 / Apex Cabling — Low Voltage Division. Notify the Safety Manager immediately for any recordable, lost-time, or serious incident. Preserve the scene and gather witness statements before crews leave the area.