Incident Report Form With this site, you will be able to submit your Incident Report Form, which will go directly to Wyatt Croft. Incident Report Form Employee(s) Involved*Was a Non-Employee Involved?* Yes No Non-Employee Name:Non-Employee Phone:Date of Incident*What time did the incident occur?*Who was the incident reported to?What time was the incident reported?*Location of the incident:Address of incident (if off-site)Were there witnesses of the incident?* Yes No Witness #1 Name:Witness #1 Phone Number:Witness #2 Name:Witness #2 Phone Number:Were photos taken of the incident? Yes No Description of the incident:*Describe Immediate Corrective Actions Taken:*How could this incident have been avoided or prevented?*InjuryWere there any injuries because of this incident?* Yes No Nature of the injuries due to this incident Abrasion, scrapes Amputation Broken bones Bruise/contusion Burn (caused by heat) Burn (caused by chemical) Concussion (to the head) Crushing injury Cut, laceration, puncture Foreign body or object Hernia Illness Sprain, strain Was first aid administered? Yes No Were any body fluids exposed?* Yes No Name of the person exposed to the body fluids:*What is the condition of the injury?* Minor Moderate Severe Is there lost time or were work restrictions imposed due to the injury?* Yes No Are the any medical treatments for this injury?* Yes No Treatment LocationWhere did you go or are you going for medical treatments as a result of this injury?Please describe the injury as a result of this incident:What caused the injury?FallSlipToolEquipmentCutHitOtherVehicleWas a vehicle involved this incident?* Yes No Driver Name:*Driver's Phone Number:*Who owns this vehicle?* CHS Owned Employee Owned Non CHS Vehicle What is the Unit #?*Enter the vehicle Year:*Enter the vehicle Make?*Enter the vehicle Model:*Location of Damage:*Please describe the vehicle damage:*Check the vehicle action when the damage happened:* Backing Changing Lanes Making a Left Turn Making a Right Turn Merging into traffic Slowing Parked (Occupied) Parked (unoccupied) Stopped Other You selected "other" vehicle action, please briefly describe:*Were the Police Called?* Yes No Was a citation issued?* Yes No Was a Drug or Alcohol Field Test given?* Yes No Were you wearing a Seat belt?* Yes No Not Applicable Please give a low estimate of the Damage:Please enter a number from 1 to 500.Please give a high estimate of the Damage:Please enter a number from 501 to 5000.Property DamageWere there any Property Damages because of this incident?* Yes No Environmental IncidentWere there any Environmental Damages because of this incident?* Yes No PhoneThis field is for validation purposes and should be left unchanged. This iframe contains the logic required to handle Ajax powered Gravity Forms.