Appendix
B
Accident Report Form
REPORT OF INCIDENT
Date of occurrence:
Report Number:
Time of occurrence:
Report type: Initial / Final
To:
From:
Date:
CC:
Location:
CATEGORY (Circle one)
Incident
Near miss
F.Y.I
INCIDENT TYPE (Circle one)
Cable cut - Excavation
Cable cut - Other
Improper Equipment Installation
Equipment/Property Damage
Injury to Personnel
Other:
PROJECT INFORMATION
Work release Number:
Project Title:
Project location:
Activity Preformed: (Circle appropriate activities)
Demolition
Excavation
Installation
Material Handling
Other:
Personnel in charge:
Title:
Contact telephone number:
Quality/Safety Representative on site: yes / no
Advisory Notices issued: yes / no
Witness(es): yes / no (If yes complete attachment A of Incident
Report)
INCIDENT INFORMATION
Indicate as appropriate:
Property Damage: yes / no
If yes, estimated cost of damage $
Disruption to Air Traffic services occur: yes / no
Endangerment to any employees or public occur: yes /
no
Brief Description of the Incident
After all aspects of the incident are analyzed, a final description will be provided
and a final report issued.
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