5_-_Accident_Report.pdf

DSC - CONTRACTOR ACCIDENT/PROPERTY

DAMAGE REPORT

Record:

Date:

Name: Trade:

Birth date:

Date of Accident: Time of Accident:

Contractor:

Project: Location:

Description of Accident: (BE SPECIFIC. DESCRIBE WHAT HAPPENED, WHERE.):

What was employee doing when injured?

Specific body parts injured?

Type of injury (i.e. Puncture, sprain, fracture, illness, etc)

First Aid? Yes No Medical Clinic? Yes No Hospitalized? Yes No

Is time loss expected? Yes No How long?

Environmental Factors:

Property Damage Involved? Yes No Describe:

Estimated dollar amount of Damages:

Corrective Action Taken:

Contractor Reporting: Date:

Project Inspector Reporting: Date:

ATTACH COPIES OF ANY ADDITIONAL INFORMATION (& photos)

COMMENTS

May 12, 2004 / Form No. CM-22