Safety · Form A-01

Accident / Incident Report

Murfreesboro, TN · 615-907-8253

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⚠ If anyone is seriously injured, call 911 first. Then call the office at 615-907-8253. Do not move an injured person unless they are in immediate danger. Fill this out once everyone is safe.

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Who is reporting

Your name *

Your role *

Date *Today, auto-filled

Date & time of the incident *

Where did it happen? *Street address or the closest cross-streets

What kind of incident

Incident type *Check every type that applies

InjuryVehicleProperty damageNear missCustomer property

People involved *List everyone directly involved, separated by commas

Injuries

Was anyone injured? *

YesNo

Describe the injuries *

Was medical treatment sought? *

YesNo

Where were they treated?

Vehicle involved

Only fill this in if a Genesis vehicle or another vehicle was part of the incident.

Was a vehicle involved? *

YesNo

Genesis unit # / plate

Police report #

Other party — name, phone, vehicle

Other party insurance company & policy #

Property damage

Describe any property damageLeave blank if nothing was damaged

What happened

Describe the incident in your own words *Facts only — no guessing at fault. The more detail, the better.

Contributing factorsCheck anything that played a part

Rushing / time pressureWet or slippery surfacePoor lightingMissing or wrong PPETool or equipment failureUntrained for the taskWeatherDistractionHousekeeping / clutterTrafficEnergized circuitUnknown

What did you do right after? *

Witnesses

Add up to three witnesses. Skip if there were none.

Witness 1

Witness name

Witness phone

Maximum of 3 witnesss reached.

Notification & photos

📷 Photos matter. Take wide shots and close-ups now, then text them to the office at 615-907-8253. Photos cannot be attached to this form.

Was a supervisor notified? *

YesNo

Who did you notify? *

What time did you notify them?

Sign off

Type your full name as your signature *Typing your name here counts as your signature on this report.

Acknowledgment *

I confirm this report is accurate and complete to the best of my knowledge.

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Genesis · Electrical · HVAC · Plumbing · Murfreesboro, TN
615-907-8253 · office@genesiselectric.llcInternal field-tech toolkit