Incident Report Name(Required) Employee Title(Required) Locate Technician Management Other NL Customer(Required) City & State where incident ocurred(Required) Date of Incident(Required) MM slash DD slash YYYY Time of Incident Hours : Minutes AM PM AM/PM Detailed description of place/location of event(Required) Please list Employee's names, Contractor names or other parties' names that were involved in the incident (First and Last Names)(Required) Type of Incident? Please check all that apply(Required) Employee or Sub-Contractor Injury Equipment Damage Company Vehicle Environmental Near Miss Good Catch Other Party Injury Security Utility Strike Other Describe "Other" Incident(Required) NL Ticket Number Describe what occurred using facts only (who, what, when, where, how)(Required)Describe what you did in response (who, what, when, where, how)(Required) What did you gather for further investigation and/or reporting? Please check all that apply.(Required) Pictures (Pre-Dig, Post-Dig, Damage, Vehicle, Equipement, PPE, etc.) Witness Statements Police Report Insurance Auto Claim Report Salvaged Damaged or Defective Equipment JHA and Associated Job Paperwork DVIR if Applicable to the Type of Incident PPE Worn One Call Ticket # Other Describe "Other" Incident(Required) Who did you notify and what time did you notify them? Please list names of manager(s). List time AM or PM(Required)FilePlease upload any images associated with the incident. Drop files here or Select files Accepted file types: jpg, jpeg, gif, png, tif, pdf, mp4, heic, mov, wmv, Max. file size: 256 MB.
