Injury or Illness Incident Report

The Injury or Illness Incident Report is to be completed by the Job Supervisor whenever there is an injury or illness on the job site of sufficient severity to warrant filing this report.

The filing of the report is at the discretion of the Job Supervisor. However, it is recommended that a report be filed for each reported injury or illness incident, no matter the severity. It is better to file a report and not need it than to need a report and not have filed it.

The OSHA FORM 301 Information form can be used in place of, or in combination with, this form.

When submitted, form responses are sent to the email addresses provided and then deleted.
IF YOU WISH TO RETAIN THE INFORMATION YOU HAVE ENTERED, ADD AN EMAIL ADDRESS BEFORE SUBMITTING.

INJURY OR ILLNESS INCIDENT REPORT

SITE SUPERVISOR
Complete upon the occurrence of any injury or illness on the job site.
PROJECT MANAGER
Copy to Project Binder, Copy to Accounting/Risk Management.
ACCOUNTING/RISK MANAGEMENT
File in Safety Compliance folder for minimum 5 years.

We are issuing an Injury or Illness Incident Report

The following information relates to the affected person

The injury or illness incident
Full names of any other persons affected in this incident.
Full names of any witnesses to this incident.

Treatment or First Aid provided

Follow-Up

Send to

When the “Send Inspection Report” button is selected, an email with all the information in this Inspection Report will be sent to the “Builder email” address of the Company Representative completing this report and to the “Subcontractor email” address and “Copy to” addresses if provided.

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