Incident Report
Bryant Group Incorporated
7891 Beechcraft Avenue
Gaithersburg, MD 20879
Use this form to document accidents resulting in injury or illness, vehicle and equipment accidents, events involving third parties, property damage, and near miss events.
Date of Incident
-
Month
-
Day
Year
Date
Time
Name of Employee, Injured Party, or Homeowner
Type of Report
*
Occupational Injury / Illness
Equipment / Vehicular
Near Miss
Property Damage
Injured Party Type
Employee
Sub-Contr.
Homeowner
Position Description
ID Number
Address (if not employee)
Addr. Line 2
City, State, Zip
Phone No.
Name, Address, Contact Information for other involved parties:
Type of Equipment or Vehicle
Tag / ID Number of Equip or Vehicle
Operator had required cert. or lic.
Yes
No
Date lic. or cert. issued & Expir.
Location of Incident
*
Job Site
Company Facility
Completed or Occupied Home
Roadway
Community ID or Name
Homeowner or Client Name
Lot No. or Address
City / State
Describe Work Area
Location of Vehicular Incident (name of roadway, cross street, nearest exit mile marker, etc.)
Treatment
Treatment Provided
*
Yes
No
N/A
Location of Treatment
Who Provided Treatment
Description of Treatment
Additional Description
Describe Type & Extent of Injury, Illness, or Damage in Detail
*
Name, Address, Phone, e-Mail, & Other Contact Information for Witnesses
Witness 1:
Witness 2
Witness 3
Witness 4
Describe Event (in detail)... working actions occurring (or not) that lead up to the incident, including any equipment or materials being utilized
Desc. of Event
*
List Identified Root Causes of the Incident
Solutions, including person(s) responsible and expected completion date(s)
Report Filed by:
*
Email Address
*
Job Title
*
Date Completed
*
-
Month
-
Day
Year
Date
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