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Emergency Response Program
Equipment Failure Report
Employee Information
Employee Name
First
Last
Role / Position
Select Role
Employee
Supervisor / PM
Subcontractor
Visitor
Phone
Failure Details
Date of Failure
MM slash DD slash YYYY
Time of Failure
Hours
:
Minutes
AM
PM
AM/PM
Location on Site
Type of Equipment
Type of Equipment
Hand Tool
Power Tool
Ladder/Scaffolding
Heavy Equipment (Forklift/Excavator)
Vehicle
Electrical System
PPE (Harness, Respirator, etc.)
Other
Description of Failure
Immediate actions taken
Supporting Documentation
Photos of Equipment / Scene
Drop files here or
Select files
Max. file size: 250 MB.
Maintenance or Inspection Records
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
