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Incident Report:  TO BE COMPLETED BY SUPERVISOR

  • Incident Types

    • Injury, Liability, Damage to CLCWA Property, Damage to CLCWA Vehicle, Other

  • Details to Include:

    • Who (All Individuals involved)

    • What and How (details leading to, during and after the incident))​

  • Email pictures of the accident (injury and/or damage) to HR@clcwa.org.

  • If utility lines are damaged,

    • Include above, 811 order#, note if ground was accurately marked, and who was notified of damage (811 and/or owner of damaged line)

    • email before dig and after dig pictures to HR@clcwa.org

  • If any non CLCWA staff member is involved in the incident,

    • email pictures of insurance information and identification to HR@clcwa.org

  • For auto accidents, make sure police are called and police report number is recorded (above).

  • If Injury, describe any onsite First Aid provided

  • If damage, provide property, vehicle, or equipment identification

  • If employee was transported to hospital or emergency care, indicate who/how transported and location transported to (above)

  • All accidents require a post-accident drug screen, even if there is not an injury.

  • Workers Comp insurance = TML policy #6161, phone 1-800-537-6655

  • Below to be completed after submittal

Report has been submitted

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