Leidal & Hart Safety App

Incident Type

Near Miss

Accident

Employee Name

Occupation

Contact No.

Address

Date of Incident

Time of Incident

Foreman/Supervisor

Contact No.

Project Manager

Contact No.

Job Name

Job No.

Jobsite Address

Specific Location on Jobsite Incident Occurred

Describe How Incident Occurred

Witness(es)

Resolution(s)

Suggested Safety Video(s) for Individual(s) Involved

Did an Injury occur?

Yes

Describe Injury

Did Employee Call the Nurse Hotline?

Was Employee Sent to the Clinic?

What Clinic Did Employee go to?

Was First Aid Provided Onsite?

Did the Foreman Call Office to Discuss Injury?

Report Submitted By

Date