THERMA

ACCIDENT/EXPOSURE

Job Site:	Date:
Investigation Team:	Job Number:
Employee Name:	Employee ID #:
Sex:	Job Description:
Department:	Time of Work (Start):
Project Manager:	Foreman:
General Foreman:	Journeymen/Leadsman:
Accident Date:	Time of Accident:
Date Reported to Supervisor:	Time Reported:
Date of Investigation:	Time of Investigation:
Nature of Incident:
Type of Injury:
Referred to Medical Facility/Doctor: Yes No Medical Facility/Doctor:
Did Employee Return to Work? Yes No Date/Time:
Injured Employee Interview/Statement:

Witnesses Interviews/Statements (Explain):

Photograph(s) of Site:(attach) Yes No Diagram(s) of Site:(attach) Yes No
Equipment Records Reviewed: Yes No Attached
Accident/Exposure Incident Description:

Root Cause:
Corrective Action Plan and Responsibility:
PPE's Used/Needed:

Please use back side for any additional information.

Additional Information: