SARGENT ELECTRIC

Date of Incident *

Time: *

AM PM

Employee’s Name *

Date of Birth *

Address *

City *

State *

Zip *

Social Security Number *

County *

Phone Number Where You Are Staying *

Home Phone Number *

Classification *

Craft *

Your Local Union Number *

Out Of:

City

State

Marital Status

Years of Craft Experience

I have reviewed and signed the “Sargent Electric Company Employee Acknowledgement” form: Yes No

I have received a copy of the Physicians Panel: Yes No

City

I have received and reviewed the “Sargent Electric Company Employee Responsibilities” form: Yes No

Location where incident took place

Category

Incident with Injury

Incident without Injury

Near Miss

Other

Describe in detail (who/what/when/where/why) exactly what happened

I assert that this form has been completed in its entirety to my best of my knowledge. Please print your name, sign & date below

Print Name *

Date *

Sign Name *

Clear Signature