FINFROCK Incident Notification Form Please enable JavaScript in your browser to complete this form.Complete this form as soon as practical after an incident occurs which results in an accident, Injury, Illness, damage to property, or near miss. Relay this form to Safety and HR as soon as possible along with any witness statements and photographs. If you are NOT an employee and have safety related concerns, please call (407) 293-4000Reason for Notification * Injury / IllnessProperty Damage/TheftNear MissOtherName *Name and title of the person filling out the reportTitle *Department(Choose)ManufacturingProduct HandlingMaintenanceTransportationErectionConstructionEmail *Contact information of the person filling out the reportPhone *Incident Date and Time *DateTimeIncident SiteApopka Manufacturing FacilityFINSOUTH Manufacturing FacilityAdministration OfficeOff-siteJob SiteOtherExact Location / Job Site Name or Number *Work Site ActivitiesClean-upForm Prep / Rebar WorkPouring / FinishingProduct HandlingPre-constructionEarth WorkErectionConstructionTransportationOtherIncident Narrative *Notable Site Conditions (Weather, Lighting, Traffic, Etc.)Attach Photos of the Incident Click or drag files to this area to upload. You can upload up to 10 files. Attach Photos of the Incident (Property Damage/Theft) * Click or drag files to this area to upload. You can upload up to 10 files. Witnesses Names and Contact InformationThis report is true and complete to the best of my knowledge. *Clear SignatureSignatureInjury / Illness ReportName of the Injured / Ill Person *Title of the Injured / Ill Person *PhoneIs This Injury Work Related? *YesNoInjured Person's Employer *FINFROCKToronto (Erection)Temporary Employee (Supervised)ContractorVisitorOtherNature of Injury / Illness *AbrasionAmputationBroken BoneBruiseBurn (Thermal)Burn (Chemical)ConcussionCrushCut/Laceration/PunctureDamage to body SystemExposureEye InjuryHerniaIllnessShockStrain or SprainPainVibration DamageOtherDescribe the Injury in DetailInjured/Ill Person Level of Pain 1-10 *12345678910Was Medical Attention Required *YesNoMedical Attention ProvidedOn-Site First AidOff-Site First AidUrgent Care / ClinicEmergency RoomOtherWas Medical Transportation RequiredYesNoTransportation Used *AmbulanceRide Share (Uber, Lift, Taxi)SupervisorOtherMedical Facility NameName of facilityMedical Facility Phone NumberMedical FacilityAddress Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeAny Additional InformationProperty DamageName of the Involved Person *Title of the Involved Person *Email Phone What was Damaged? *EquipmentToolVehiclePieceOtherIdentification of Damaged Object *VIN number, piece number, equipment description, etc.Who Owns the Damaged Object *FINFROCKCustomerContractorOtherDescription of the Damage *Is the Damage Repairable?YesNoNext Steps (Repaired / Replaced by Whom?)Owner Notified?YesNoOwner Contact InformationNameAddressAddress Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeAny Additional InformationThis report is true and complete to the best of my knowledge. *Clear SignatureSignatureAt the request and instruction of Finfrock’s legal counsel, Finfrock’s Executive Safety Committee and/or Finfrock’s Human Resource Department, acting as investigators for Finfrock’s legal counsel, the attached photo(s) and report(s) is/are being provided for the purposes of gathering facts and information for the obtaining of legal advice. This notification will only be sent to the Safety Department. Safety will coordinate with other departments as needed.>Submit