Statement of Work - Attachment 14 - 01 35 26 - Attachment A Accident Investigation

Initial Report
Follow-up Report
Final Report

Contractor Incident Report System (CIRS)

1. Contract Information

Incident Information

Prime Contractor:

Cage Code:

Contract Number:

Installation of Incident:

Task Order #:

Contracting Activity/ROICC Office:

Contractor Contact Information
Name (Last, First):

Phone #:

Email Address:

Date Notified:

2. Incident Type

(Please Check/Bold All That Apply)

Assault/Violent Act

Extreme Environmental Exposure

Man over the side (No water entry)

Diving

Falls, slip, trip, or bodily exertion

Man Overboard - Water Entry

Electrical Shock/Burns

Fires - All Types

Material Handling Equipment

Equipment
Installation/Repair

Hazardous Material (any type)

Ordnance-Related (Explosive)

Explosion, Non-Ordnance

Industrial
(Select Additional Below)

Vehicle (Government or Private)

Industrial Incident Additional Information

(Please Check/Bold All That Apply)

Confined Space

Hand and Power Tools

Work Platforms and Scaffolding

Demolition/Renovation

Rigging

Underground Construction, Shafts, and
Caissons

Trenching/Entrapment

Cranes and Hoisting Equipment

Concrete, Masonry, Steel Erection and
Residential Construction

Traffic Control

Floating Plant and Marine Activities

Tree Maintenance and Removal

Welding and Cutting

Pressurized Equipment and System

Airfield and Aircraft Operations

Control of Hazardous Energy

Fall Protection

Contractor Incident Report System (CIRS)

3. General Information

Incident Information

Date of Accident:

Time of Accident:

Describe the accident in detail in your words: (Use the back of page if you need additional space)

Exact Location of Accident:

Were Hazardous Material(s) Involved

Yes

No

If Yes, Explain What Hazardous Materials Were Involved and Why:

Who Provided Clean-up?

Onsite

Base

Public

Activity of the injured person at the time of incident:

Personal Protective Equipment: (Check/Bold Response)
Available and used

Available and not used

Not related to Mishap

Wrong PPE for job

Not Required

List PPE Used:

Contractor Incident Report System (CIRS)

4. Fully Explain What Allowed or Caused the Incident:

Incident Information

Direct Cause:

Indirect Cause:

Additional Action Taken: (Please Include a Begin Date and Est. End Date in Description)

Additional Action Taken: (Please Include a Begin Date and Est. End Date in Description) (Use the back of page if you need additional space)

5. Contributing Factors:

Was Visibility Restricted?

Unit of Measure (Check/Bold):

Yes

No

Feet

Distance Visibility was restricted:

Yards

Meters

Miles

Nautical Miles

Visibility Restricted By: (Check/Bold all that apply)
Fog