SARGENT ELECTRIC

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(Please input all fields marked with *)

Job *

Customer *

Jobsite Description *

Jobsite Location *

City *

State *

Site Phone

Category

Incident with Injury

Incident without Injury

Near Miss

Other

Date Of Incident *

Time *

Location of incident on jobsite

Name Of Employee Involved

SS Number *

Description of Incident:

Is this a lost time injury?: Yes No

Last full day paid

Hourly Rate

Situation: What was the employee doing when the incident occurred?

Analysis: Why did the incident occur? Please be specific

Prevention: What has been done to prevent similar occurrences?

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

First Name *

Last Name *

Date Of Birth *

Sign Name *

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