Incident Report
Time-Sensitive Reporting
- Fatality: Call OSHA within 8 hours — 1-800-321-OSHA
- Hospitalization, amputation, or loss of eye: Call OSHA within 24 hours
- This report: Complete within 24 hours of the incident
- Notify VidIn PM: Immediately — do not wait to file this form first
Section 1 — Incident Information
Report Date: ______________________ Time Completed: ______________________
Incident Date: ______________________ Time of Incident: ______________________ AM / PM
Exact Location (address + area/room):
Project Name / Job Number: ______________________
Site Contact (GC or client name and phone): ______________________
Section 2 — Person(s) Involved
Name: ______________________ Role: ☐ VidIn Employee ☐ Subcontractor ☐ Other: ______
Company (if subcontractor): ______________________
Time on Site Today Before Incident: ______________________
Witnesses (name and contact for each):
| Name | Contact / Phone |
|---|---|
Section 3 — What Happened
Describe what the person was doing immediately before the incident. Include the task, tools or equipment being used, and location.
Describe how the incident occurred. What was the sequence of events? What went wrong?
What object, substance, or condition directly caused the harm? (e.g., ladder, electrical circuit, heavy cabinet, wet floor)
Section 4 — Injury / Illness
Was anyone injured or made ill? ☐ Yes ☐ No
If yes, complete this section:
Nature of injury or illness: (e.g., laceration, fracture, electric shock, strain)
Part of body affected: ______________________
Severity:
☐ First aid only — treated on-site
☐ Medical treatment — went to clinic/urgent care
☐ Emergency room visit
☐ Hospitalization (overnight)
☐ Fatality
Medical facility visited (if any): ______________________
Was the person able to return to work? ☐ Yes, same day ☐ Yes, with restrictions ☐ No
Section 5 — Property or Equipment Damage
Was any property, equipment, or the client’s facility damaged? ☐ Yes ☐ No
If yes:
What was damaged? ______________________
Estimated damage: ______________________
Photographs taken? ☐ Yes — attach or link ☐ No
Section 6 — Immediate Actions Taken
- First aid administered — describe: ______________________
- 911 called
- Work stopped in affected area
- Site contact notified — name: ______________________ time: ______________________
- VidIn PM notified — time: ______________________
- OSHA notified (if required) — time: ______________________ confirmation #: ______________________
- Hazard secured or barricaded
- Other: ______________________
Section 7 — Preliminary Root Cause
Check all that apply:
Work Environment
- Inadequate lighting
- Wet or slippery surface
- Congested or cluttered work area
- Inadequate barricading or signage
- Unexpected change in site conditions
Equipment / Materials
- Defective or damaged tool/equipment
- Wrong tool or equipment for the task
- Improper material handling
- Equipment failure
Human Factors
- Inadequate training for the task
- Fatigue
- Bypassed safety procedure
- Distraction
- Task not communicated clearly
Procedure
- No procedure existed for this task
- Procedure was not followed
- Procedure was inadequate
Additional notes on root cause:
Section 8 — Corrective Actions Required
List actions to prevent recurrence. Assign an owner and due date for each.
| Action | Owner | Due Date | Completed |
|---|---|---|---|
| ☐ | |||
| ☐ | |||
| ☐ |
Section 9 — Certification
Completed by: ______________________ Title: ______________________
Signature: ______________________ Date: ______________________
VidIn PM Review: ______________________ Date: ______________________
Recordkeeping: Retain this report for a minimum of 5 years per OSHA 29 CFR §1904. File in the project folder and send a copy to the VidIn PM. If VidIn has more than 10 employees at any point in the year, log recordable incidents on OSHA Form 300 within 7 calendar days.
Template Version: 1.0 | Last Updated: February 22, 2026 Owner: John Lang | jlang@vid-in.com OSHA Reporting Hotline: 1-800-321-OSHA (6742) Reference: OSHA Form 301 equivalent — 29 CFR §1904.29