INCIDENT/ACCIDENT REPORT AND ASSESSMENT
Incident/Accident Report and Assesment in PDF format
Incident/Accident Report and Assesment in MS Word format
To be completed by field trip leader in the event of an incident
involving serious injury
and/or damage to property, and filed with LOC Safety Officer or
Section/Division Head or
designate)
| Name of Person Involved (PRINT)
|
Date of Occurrence
|
Time
|
| First Aid or Medical Attention Required:
Yes: _____ No: _____ |
Damage to Equipment:
Yes: _____ No: _____ |
|
| Field Trip Leader's Name
|
Field Trip Leader's Signature
|
|
| Report Date
|
Reported By
|
|
| Reported To (police, other authority)
|
Copy Sent to GAC® Safety Committee
Date: |
|
| Date of Notification
|
Field Trip Participant's Signature
|
|
| Workers Compensation Form Completed?
Yes: _____ No: ______ (If Yes, Please Attach Copy) |
Date of Completion of Form
|
|
| Location of Occurrence (Outcrop, Highway, City, etc.)
|
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| Other Personnel Involved in Incident/Accident
|
||
| Field Trip Participant's Report of Incident/Accident.
Describe Activity That Led to Incident/Accident Stating What Equipment
(e.g., tools, etc.) Was Involved. Describe the Nature and Cause of the
injury.
|
||
| Are There Any Witnesses? Yes: _____ No: ______ | ||
| Names and Addresses of Witnesses
|
||
|
Statements of Witnesses First on Scene of Incident/Accident |
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| Statements of Other Witnesses
|
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If more space is required use a separate sheet of paper.