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Emergency Response Program
Fire or Hazard Report
Employee Information
Employee Name
First
Last
Role / Position
Select Role
Employee
Supervisor / PM
Subcontractor
Visitor
Phone
Incident Details
Date of Incident
MM slash DD slash YYYY
Time of Incident
Hours
:
Minutes
AM
PM
AM/PM
Location on Site
Type of Event
Type of Event
Active Fire
Smoke / Smoldering
Electrical Hazard
Chemical Spill / Fumes
Gas Leak / Odor
Structural Hazard
Trip / Fall Hazard
Other
Describe What Happened
Was 911 called?
Yes
No
Was the area evacuated or barricaded?
Yes
No
Is the hazard still active?
Yes
No
Immediate actions taken
Supporting Documentation
Photos / Video (scene/equipment)
Drop files here or
Select files
Max. file size: 250 MB.
Relevant documents (SDS, notes)
Drop files here or
Select files
Max. file size: 250 MB.
Signature / Acknowledgement
Supervisor / PM notified?
Yes
No
Who was notified & when?
I confirm this information is accurate to the best of my knowledge.
Signature
