CLS Incident/Accident Report

Complete the below form for any incident, accident or loss occurred while on company time or on company property. This includes vehicle accidents, damaged, lost or stolen equipment or tools, workplace injuries, or other notable incidents not otherwise listed.

Section 1. Demographics

Location Name(Required)

Where did the incident occur? (Contract name, shop location, etc.)

Date of Incident(Required)

MM slash DD slash YYYY

Time of Incident(Required)

Hours

:

Minutes

AM PM AM/PM

Location Address(Required)

Where did the incident occur? (Highway/Roadway name, )

Section 2. Injured Person Contact Information

Complete only if injury occurred during incident. If no injury occurred, please skip to Section 3.

Name

First Last

Home Address

Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code

Phone Number

Email Address

Section 3. Description of Property Damage/Incident

Please explain the nature of the incident.(Required)

Include as many details as possible. Loss of tools/equipment, people involved, how the incident occurred, property damage or injury, etc.

Police Department Contacted?(Required)

Yes

No

Ambulance Called?

Yes

No

Transported?

Yes

No

If yes to above, please provide the Department Name

Report Number

Is there video/dashcam footage of the incident?(Required)

Yes

No

If yes, please preserve dashcam footage and transport SD card to Havana office for review.

Photos taken of the incident/injury?(Required)

Yes

No

If yes, please upload photos under Section 6 below.

Section 4. Injured Party Information

If injury involved, was medical treatment required?(Required)

Yes

No

No Injury Involved

Name of Medical Facility

Facility Address

Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code

Medical Facility Phone

Section 5. Witnesses

Witness 1 Name

First Last

Witness 2 Name

First Last

Phone

Email

Phone

Email

Witness 3 Name

First Last

Witness 4 Name

First Last

Phone

Email

Phone

Email

Section 6. Photo Documentation of Incident

Damage/Loss Photo 1

Damage/Loss Photo 2

Damage/Loss Photo 3

Damage/Loss Photo 4

Damage/Loss Photo 5

Damage/Loss Photo 6

Damage/Loss Photo 7

Damage/Loss Photo 8

Damage/Loss Photo 9

Damage/Loss Photo 10

Section 7. Person Completing Report/Signatures

Name(Required)

First Last

Date of Report(Required)

MM slash DD slash YYYY

Job Title

Phone(Required)

Email(Required)

Signature(Required)