Date and Time of Accident

Location (Area)

• Maintenance Room

• Service Line

• Public Area

Reporter Name

Job Title/Role

Company Name

Phone number

Email

Name of Injured Employee

Incident Description

Provide a detailed account of the incident. Include events leading up to, during, and following the occurrence.

Type of Incident

• Electrical Hazard (e.g., shock, fire)

• Water Leak/Flooding

• Gas Leak/Explosion

• Sewer Backup or Overflow

Utility Involved

• Electricity

• Gas

• Water

• Sewer

Condition of Utility Before Incident

Witness Name 1

Phone number

Witness Name 2

Phone number

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Were there any injuries?

• Yes

• No

Description of Injuries

Describe the type and severity of injuries. Specify who was injured and their condition.

Was medical attention provided?

Immediate Actions Taken

Describe actions taken to address the incident, such as shutting off utilities, calling emergency services, or repairs.

Was property or infrastructure damaged?

• Yes

• No

Description of the Damage

Was the incident reported to a supervisor or utility manager?

• Yes

• No

Supervisor/Utility Manager Name

Phone Number

Additional Comments

Include any further information, suggestions, or recommendations to prevent future occurrences.