Project Incident Notification Report Template

Attorney/Client Privileged? Yes No

Legal Privilege Statement Confidential: Attorney/Client Privileged
Attorney/client privileged incident reports are prepared at the direction of Counsel in anticipation of litigation and/or seeking legal advice to protect
CWJV interests. Attorney/client privileged incident reports may not be further distributed within the company or outside the company to any third
party without the expressed written permission of the Corporate Legal/Risk Management Counsel.
SECTION 1. INCIDENT TYPE (Select Only One)
SERIOUS
Fatality Injury/Illness Environmental (L1/L2) Significant HSSE Action Significant Property Damage Significant Near Miss
OTHER

LWDC Recordable Case Environmental (L3) Non-significant Property Damage Non-significant Near Miss Utility Hit
SECTION 2: PROJECT DETAILS
Office/Project Name: Site Manager Name: Sr. HSSE Rep. Name:

Project Number: Contact #:

Contact #:
Project Location: Contractor Entity(s): Employer:

SECTION 3. EMPLOYEE INFORMATION (Required ONLY for Injury/Illness Incidents)

Injured Employee Name: (If Subcontractor) Company relationship to:
(Last, First, MI):
Subcontractor Sub-tier level (1-9)

Employee ID Number: Site Hire Date: Trade Start Date: Employer (Company name):

SECTION 4. INCIDENT SUMMARY

Incident Date (dd/mm/yy): Time of Incident (24hr): Incident Location: Shift:
Activity in progress at time of incident.

Name of Witness/s:

SECTION 5: INJURY/ILLNESS DETAIL (if

applicable): Check if NOT applicable
Injury, Illness? If applicable, briefly describe nature of injury/illness:
.
Injury Illness

SECTION 6: NEAR MISS DETAIL (if applicable): Check if NOT applicable

Perceived potential risk of:

Fatality/Injury/Illness Environmental Damage Property Damage Utility hit / Service Interruption

Additional Information/Details Specific to Near Miss Event (attach additional sheet if necessary):

SECTION 7: ENVIRONMENTAL DETAIL (if

applicable): Check if NOT applicable
Severity: Impact(s):
Level 1 Agency enforcement action Other instance requiring off-project notification
Potential offsite impact to human health or environment Potential impact to water resources
Level 2
Sub-contractor-initiated action Spill of hazardous substance w/no environmental impact
Employer initiated action (i.e., shutdown) Release of hazardous substance above Reportable Quantities
Level 3
Shutdown/work stoppage Spill of hazardous substance below Reportable Quantities
Incident requiring action w/no environment impact Spill of hazardous substance offsite
Non-compliance order Spill of hazardous substance in waterway

SECTION 8: PROPERTY DAMAGE DETAIL (if applicable): Check if NOT applicable

Category: Impact: Value Category:
Construction equipment None Fire <$500,000
Non-vehicle Project only Vandalism ≥$500,000
Vehicle – At fault Public involvement – No third party
Vehicle – Not at fault Public involvement –Third party
Description of Property Damage:

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 Project Incident Notification Report Template

SECTION 9: UTILITY HIT/SERVICE INTERRUPTION DETAIL (if

applicable) Check if NOT applicable
Type of Utility: Impact: Utility Company contact information:
Electric Gas Impact to Public
Water/Sewer Telephone/cable/fiber optics No impact to Public
SECTION 10: SIGNIFICANT HSSE ACTION DETAIL (if applicable and if
known) Check if NOT applicable
Category: Details or additional information (if applicable):
Regulatory
Police, government or diplomatic investigation
Criminal charges
Media Coverage
Liability or charges against CWJV
SECTION 12: TOTAL LOSS POTENTIAL
Risk Severity: Risk Probability: Total Loss Potential:
SECTION 13: CAUSAL ANALYSIS. Use best professional judgment to identify the likely cause or causes of the incident, citing facts and
evidence that support your conclusions. Identify any data gaps or critical uncertainties. Use the Causal Factor Checklist in Attachment 4 as a
guideline and consider whether any of the factors listed on the Checklist pertain to the incident under investigation
Causal Factors:

Root Cause(s):

SECTION 14: CORRECTIVE ACTIONS/LESSONS LEARNED. Briefly summarize corrective actions taken following the incident, either interim
or longterm,or both. Also describe Lessons Learned (if applicable)
Action Responsible Person(s)
1.
1.
2.
3.
4.
Lessons Learned:

SECTION 15: ATTACHMENTS (List attachments as appropriate, examples include the following):
Pictures (use Photo Information Sheet) Tool Box Note Witness Interviews
Training Records Equipment Specs 3rd Party Incident Report
Investigator Notes Team Members Permits
Time Line

Prepared by:
Signature: Date:

Required Distribution: Restricted to the following Individuals for Serious Incidents:

Project Manager Site Manager Name:
Deputy Project Manager Site Manager(s) Name:
Name:
Site Manager(s)
Name:
HSSE Manager Name:

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 Project Incident Notification Report Template

Employee Interview (to be completed by Investigator)

Project Name: Project Number:
Date of Incident: Time of Incident:
Name of Employee: Position:
Superintendent/Construction Manager:
Supervisor/General Foreman:
Foreman:
Name of Interviewer:
Employee Involvement/ Description of Incident:

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 Project Incident Notification Report Template

Photo Information Sheet (may substitute with electronic photos and information)

Project Name: Project Number: Date of

Incident:
Photo No.
Photo Date:
Time of Day:
Location:
Brief Description:
(Provide direction of photo)

Notes:

Photographer:
Photo No.
Photo Date:
Time of Day:
Location:
Brief Description
(Provide direction of photo)

Notes:

Photographer:

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