Worksite Incident Report Checklist

Something happened on the construction site. Utilize this checklist to record what happened to ensure pertinent information is collected.

Question	Response Type
1. Is this a serious emergency requiriung immediate medical attention? If yes, call 911.	Yes No N/A
2. What is the name(s) and title(s) of the person(s) involved?	Text Answer
3. Has anyone involved sustained any injuries?	Yes No N/A
4. If yes, please provide a description of the injury or injuries.	Text Answer
5. Where did this take place?	Text Answer
6. Provide a breif description of what happened.	Text Answer
7. Was any property, material or equipment damaged?	Text Answer
8. If yes, please provide a description of the damage.	Text Answer
9. What could have been done to prevent this incident?	Text Answer
10. Has anyone notified the general contractor of this incident?	Yes No N/A

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