JCREMC Incident ReportIncident Type JCREMC Property Damage Non-JCREMC Property Damage Near Miss Injury Vehicle AccidentDate(Required) MM slash DD slash YYYY Time(Required) : Hours Minutes AMPM AM/PMEmployee(Required)Job Title(Required)LocationVehicle NumberWork Order #Witness to IncidentPersons InvolvedMedical Attention Required(Required) Yes NoWere Pictures Taken(Required) Yes NoWas safety equipment provided? Yes NoWas safety equipment used properly? Yes NoWas this incident on a Regular Job Assignment Trouble Call After Regular ShiftCause of incident Equipment Failure Human Error Weather If locates were permitted, was it marked properly? Yes No Weather ConditionsDescribe the IncidentList any factors/conditions that may be significant in reporting this incident to the insurance company: (include comments made by claimant, temperature, line height, voltage, etc.) Prepare and attach a diagram. Include accurate measurements and reference distances to point of damage.Ways to prevent incident in the futureInvestigation Team Use Only (if applicable)Investigation needed? Yes No State of Indiana accident report filed? Yes NoOther investigations? Yes NoNear Miss Rating12345N/AInvestigation Team Review Date MM slash DD slash YYYY Signature of RepresentativeSafety Committee Review (if applicable)Safety Committee Chairman SignatureSafety Committee Review Date MM slash DD slash YYYY FileMax. file size: 25 MB.PhoneThis field is for validation purposes and should be left unchanged.
