Quench Accident, Incident, and Near-Miss Reporting Form *(For Manager Use Only)
Section 1: Who was involved in the incident?
Provide the details of the Quench employee was was involved in the incident or reported the near-miss.
Name of the employee involved or injured:
*
First Name
Last Name
Employee's Job Title
*
Employee's Work Location (Branch, DC, Office)
*
Employee's Department?
Field Service
Supply Chain
Other
Employee's Quench Email
*
example@example.com
RSD
Please Select
Beatty, Robert
Desmond, Richard
Healy, Jason
Perez, David Kenji
Peterson, Daryle
Porras, Giovana
Reinhold, Michael
Smith, Gerald
Thompson, Austin
Region
Please Select
East
Central
West
Section 2: Who is reporting the incident?
Your name:
*
First Name
Last Name
Your Job Title
*
Your Quench email address:
*
example@quenchwater.com
Section 3: Details about the incident or near-miss.
Reporting Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Date of Incident
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Time of Incident
*
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Is this a Rental Vehicle
Yes
No
Vehicle VIN Number (if a Quench truck was involved)
*
Vehicle Unit Number
*
Location of Incident
*
Location of Incident
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Details of where the accident/incident took place
*
Describe how the accident/incident occurred (give a cause where possible)
*
Details of Accident/Injury
*
Was the Quench employee involved in the accident/incident wearing PPE?
*
Yes
No
N/A
Did the Quench employee involved in the incident/accident have all Quench required PPE on available on their truck?
*
Yes
No
N/A
Was the Quench employee involved in the incident/accident using customer or location supplied PPE?
Yes
No
N/A
Pictures of Accident/Incident
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Please attach images of Vehicle accidents/incidents only*
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For all Personal accidents and injuries, please contact Julio and HR.
Section 4: Details of any witnesses to the event.
Name of Witness
Non-Quench Employee
Witness Contact Phone Number
Witness Email
example@example.com
Witness Occupation/Role:
Witness Employer (if Quench Customer)
Witness Statement
Attach Copy of Witness Statement (if applicable)
Browse Files
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Section 5: Police Report
Has a Police Report Been Filed?
*
Yes
No
If yes, please email a copy of the police report to fleet@culliganquench.com
Browse Files
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Section 6: Repairs
Does this vehicle require repairs?
*
Yes
No
Section 7: Confirmation of Information
To be completed by the person filling out this Jotform: I confirm that the information I have provided in this form to my employer, Quench USA Inc., is true and accurate to the best of my knowledge.
Name
*
First Name
Last Name
Signature
*
Submit Form
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