Data Report
Data Report
Incident Type
Near Miss
Accident
Employee Name
Occupation
Contact No.
Address
Date of Incident
Time of Incident
Foreman/Supervisor
Contact No.
Project Manager
Contact No.
Job Name
Job No.
Jobsite Address
Specific Location on Jobsite Incident Occurred
Describe How Incident Occurred
Witness(es)
Resolution(s)
Suggested Safety Video(s) for Individual(s) Involved
Did an Injury occur?
Yes
No
Describe Injury
Did Employee Call the Nurse Hotline?
Was Employee Sent to the Clinic?
What Clinic Did Employee go to?
Was First Aid Provided Onsite?
Did the Foreman Call Office to Discuss Injury?
Report Submitted By
Date
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Peabody, Inc.
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