Witness to Incident and Injury Form

Name of witness:*

Name of person injured:*

Date of incident:*

Time of incident*

:

Location:*

Where did the incident occur?

At Plant - Above Ground or Below Ground:*

Was the incident on the surface or below ground (i.e. Tunnels)?

Specific Plant Location (above ground)*

Other Plant Locations (above ground):*

Specific Plant Location (below ground - i.e. Tunnels)*

Which Tunnel Entrance was the incident located closest to?

Service Address:*

Street Address Address Line 2 City

Description of Street/Field Location:*

Please describe the location using approximate distance from nearest intersection or point of reference.

Describe the Other Location:*

Name of Lift Station

Description of Location*

Please provide more information about the location specifics. Ie. Northeast corner of primary clarifiers or basement of resident's property

What were you (the witness) doing at the time of the incident?*

How and when did you become aware of the incident?

What did you hear at the time of the incident?

Describe what you saw at the time of the incident:

Who else was present?

Please relate any additional information you may have pertaining to the incident:

Photos

Do you have photos to help the Safety Committee understand this accident and injury? Please upload them here.

Drop files here or

Max. file size: 64 MB.

Review