Evolution Design Build Group

This is documenting on:

Details of person injured or involved.

Details of person injured or involved: (to be filled in by person injured/involved if possible)

Person Completing Report:

Date:

Person(s) Involved:

Equipment or Truck ID:

Free Text

Details of Event:

Date:

Location

Time:

Witnesses:

Description of Events: (describe tasks being performed & sequence of events)

Was event/injury caused by an unsafe act or condition: (activity, movement, machine, weather, etc.)

To be completed only if lost time/injury or first aid was required.

To be completed only if lost time/injury or first aid was required.

Type of injury sustained:

Cause of lost time:

Was medical treatment necessary?

Yes

If yes, name of hospital of physician:

Signature:

6546 N. Landmark Drive, Suite C

PO Box 982290

Park City, Utah 84098

Developed by | Buildertrend