Incident Reports | Max Kelli Homes

01

Incident details

Incident date *Time * Arizona time

Job site / location *

Person(s) involved *Supervisor / person notified *

Incident type * Select all that apply

InjuryProperty damageNear missOther

02

Describe the incident*Injuries or property damageImmediate actions taken / care provided*Witness name(s) / contact informationFollow-up needed

03

Completed by / typed signature *Date *

Supervisor signature optional

Only complete this section if the supervisor is present and signing.

Supervisor typed signatureDate

I confirm this report is accurate to the best of my knowledge. My typed name is my signature.

This report will be saved for Steven Palmer to review.